What is Pressure Ulcer?
Pressure injuries, often called bedsores or pressure ulcers, are wounds that form on the skin and soft tissues beneath it. These usually happen due to persistent pressure and rubbing on parts of the body where bones are close to the skin surface. Usually, they are found on the lower back, buttocks, and thigh bone, but can develop elsewhere, like the back of the head, shoulder blade, elbow, heel, ankle, shoulder, and even ear. Medical devices or even personal cell phones can also cause pressure injuries if they are in contact with the skin for too long.
Pressure injuries come in different degrees of severity and have different characteristics. To simplify communication between medical professionals, particular classifications for these injuries have been created. The two most recent ones were defined by the NPIAP and the International Statistical Classification of Diseases and Related Health Problems (ICD-11) in 2018 and 2019.
The COVID-19 pandemic caused a rise in pressure ulcers, leading to increased national health costs, shedding light on this issue.
Jean-Martin Charcot, a French doctor in the 19th century, studied these wounds and observed that patients who developed scab-like tissue on their buttocks and lower backs often died sometime afterwards. He called this lesion “decubitus ominous,” meaning that this wound was a sign of impending death.
In 2016, the organization responsible for pressure ulcer terminology, the NPUAP, updated its guidelines and now prefers “pressure injury”. This term better describes all types of tissue damage, including the stage before the skin breaks down. They also renamed themselves to the National Pressure Injury Advisory Panel (NPIAP) to reflect their updated terminology.
What Causes Pressure Ulcer?
Pressure injuries, also known as pressure ulcers, are wounds that develop when there is too much pressure on the skin. This can be due to several factors both inside and outside the body. Outside the body, prolonged pressure, friction, and moisture can cause these wounds. Internally, things like poor nutrition, anemia (a condition where your body lacks enough healthy red blood cells), and problems with your blood vessels can all speed up the process of tissue damage.
There are several risk factors for developing these injuries. Apart from the inability to move, wet skin, poor nutrition, and a loss of feeling are the most common. However, being older, problems with memory or thinking, and having other health conditions that make it harder for wounds to heal can also increase the risk.
When pressure on the skin is too much for too long, it can block the small blood vessels that supply oxygen to the area. This can cause the tissue to start accumulating toxic substances and dying. In fact, being immobile for just two hours is enough to start the process of forming a pressure injury in someone who is bedridden or having surgery.
Issues with the nervous system, which is responsible for regulating blood flow to local areas, can also contribute to the formation of these ulcers.
People are more likely to develop pressure injuries if they have certain conditions. These include neurological diseases (issues with the nervous system), cardiovascular diseases (issues with the heart and blood vessels), dehydration, malnutrition, low blood pressure, are having surgery or under prolonged anesthesia.
Risk Factors and Frequency for Pressure Ulcer
Pressure ulcers are a significant global health problem, affecting thousands of people every year. In particular, up to 3 million adults in the United States experience this issue annually. These injuries also put a great financial strain on the healthcare system, with costs for hospital-acquired pressure injuries potentially exceeding $26.8 billion. According to a study, about 8.3 out of every 100 seriously ill patients might develop a hospital-acquired pressure injury, which aligns with past research showing that around 7.9% of patients at risk experience this issue.
Sacral decubitus ulcers, a type of pressure ulcer, often occur in elderly, incontinent, paralyzed, or weak patients. These ulcers are less likely to form in individuals with normal senses, mobility, and mental clarity as these folks naturally make regular physical movements due to their body’s feedback system. Among all the patients who develop these ulcers, two-thirds of them are usually more than 70 years old, showing the higher risk amongst the elderly. In some cases, 83% of patients in hospitals develop these ulcers within just 5 days of being hospitalized.
Signs and Symptoms of Pressure Ulcer
Pressure ulcers or sores, often found in people with limited mobility, are usually caused by long-lasting pressure on the skin. Typically, our discomfort or pain signals us to shift our body positions. However, people who suffer from pressure ulcers might not experience this discomfort due to reduced sensation at the sore site, leading them to be unaware of their wound. Their caregivers are usually the ones who notice these injuries, often as a result of discharges of pus or blood staining the patient’s clothes or bedsheets. The appearance of these sores varies depending on their location because different body parts, like skin, muscle, and soft tissue, react differently to pressure.
Common locations where pressure ulcers form are the sacrum, ischial tuberosity, and greater trochanter. Other susceptible areas include the occiput, scapula, elbow, heel, lateral malleolus, shoulder, and ear. The muscle damage can occur before skin breakdown, making it harder for medical professionals to identify the depth or extent of the ulcer.
It’s essential to have a comprehensive understanding of the patient’s health history and overall health status. Any existing neurological or cardiovascular disease increases the chances of developing pressure ulcers and makes healing more challenging. The patient’s mental status or cognitive impairment, mobility, hydration, and nutritional status should also be assessed.
When evaluating patients with pressure ulcers, the medical professional should thoroughly understand the patient’s history, such as:
- How long the patient has been immobile or bedridden
- The duration of hospital stay
- Any medical cause that could have led to the injury, including paraplegia, quadriplegia, stroke, or a road traffic accident leading to immobility
- The history of the injury, where it first developed, how long it’s been present, and if the size has changed
- The patient’s history of any diseases that could potentially slow wound healing, like diabetes, peripheral vascular disease, or cancer
- Whether the patient can pinpoint the exact location of the ulcer and express any associated pain or if they are unaware due to a condition such as paraplegia
- If there’s been any discharge or foul odor from the ulcer site
Testing for Pressure Ulcer
If a you think you might have a pressure injury (PI), also known as a pressure sore or bed sore, your doctor will want to know a lot of details about your symptoms in order to determine what’s going on. They’ll ask about any past history with similar sores, including what might have caused them, how long you had them and how they were treated. They’ll also want to thoroughly examine the current wound to understand how deep it is and how large the affected area is.
The doctor will also check if there are sinus tracts, undermining or tunneling. In layman’s terms, these are just different ways that the wound can extend beneath the skin. The doctor will want to know if your sore is draining any liquid and if there’s any dead tissue around it.
Your doctor will also probably use something known as a ‘risk assessment instrument’. These are tools that can help predict whether a PI is likely to get worse. According to current medical literature, the most commonly used tool is the Braden Scale.
This scale takes into account several factors. It looks at your level of sensation, or your ability to feel pain or discomfort, on a scale of 1 to 4. It also considers mobility, or how well you’re able to move around, and moisture, how wet or dry your skin generally is. The scale factors in your general nutrition, or the quality of your diet, and also your level of physical activity, or how much you move around during the day. Lastly, the scale considers friction and shear, which simply means the amount of force your skin routinely rubs against things like clothes or bedding.
Based off these factors, the Braden Scale assigns you a risk score. A score between 15 to 18 means a mild risk of PI. A score between 13 and 14 means a moderate risk. A score from 10 to 12 signifies a high risk. And finally, a score of 9 or below means a very high risk of developing a pressure injury.
Treatment Options for Pressure Ulcer
Before going into the various ways to treat pressure sores (wounds that occur due to sustained pressure on certain body parts), it is important to note that the best strategy is prevention. Prevention involves improving the skin’s ability to withstand pressure and removing the pressure from those vulnerable areas. This can be done by taking good care of the skin, drinking plenty of water, eating a balanced diet, using special cushions that distribute pressure evenly, turning over regularly when in bed or a chair, and using supportive surfaces designed for this purpose. For people who find it hard to eat enough, nutritional supplements might be beneficial.
Despite best efforts, if a pressure sore occurs, the first thing to do is to relieve pressure on the affected area, clean any infection that may be present, remove dead tissue, and offer optimal wound care. It’s crucial to reposition the patient often and use special beds and dressings to reduce pressure on the wound – much like the prevention strategies. If an abscess (a pocket of pus) develops, it should be drained. Temporary use of treatments like iodine, silver sulfadiazine, hydrogen peroxide, or Dakin solution can help in cases of infection. However, these can slow down the wound healing process over time. Antibiotics are typically considered only when there are clear signs of skin infection or general signs of infection in the body. Interestingly, studies have found that even when the bone in sacral pressure sores is exposed, there’s a low chance of bone infection.
A technique called mechanical debridement, which involves removing dead tissue and biofilms (a group of microorganisms that stick together) that prevent wound healing, is typically needed. Different types of wound dressings are chosen based on the stage of the ulcer, whether an infection is present, and the amount of fluid being produced by the wound; silicone foam dressings are generally recommended.
Depending upon the location of the ulcer, it might be necessary to manage urinary and fecal output to prevent them from contaminating the wound. The depth and severity of the ulcer will determine if surgery is needed, which aims to remove dead tissue and prepare the wound for closure. A technique called vacuum-assisted closure or negative pressure wound therapy may be a preoperative option to prepare the wound. In cases where surgery is needed, the goal is to fill the void left by the wound and provide durable coverage through the use of a skin flap. Ideal candidates for surgery have stage 1 or 2 wounds without pus, a well-healed base, and the wound is well-protected from soiling.
Potential surgical treatments include surgical debridement (removal of dead or infected tissue or bone), skin graft (though not ideal for later-stage wounds due to their tendency to fail), or the use of various skin flaps taken from other body parts. The choice of flap depends on where the wound is, whether the patient needs to move around, and any other health conditions the patient may have.
Some research suggests that hyperbaric oxygen therapy (treatment in which you breathe in pure oxygen) can aid in wound healing by improving oxygen levels at and around the wound.
In treating pressure sores, the main principles are: preventing new sores, reducing pressure on existing wounds, managing the wound appropriately, surgical intervention if necessary, and improving nutritional status to aid healing. Generally, stage 1 and 2 pressure sores can be managed without surgery, while stage 3 and 4 sores might need surgical intervention.
What else can Pressure Ulcer be?
When trying to diagnose pressure ulcers, doctors might consider several other conditions that have similar symptoms. These include:
- Diabetic ulcers
- Venous ulcers
- Pyoderma gangrenosum (a rare skin disorder)
- Osteomyelitis (bone infection)
- Dermatitis (skin inflammation)
It’s crucial for the doctor to evaluate all these possibilities through proper tests to reach an accurate diagnosis.
What to expect with Pressure Ulcer
The outlook for patients with bedsores, also known as pressure ulcers, can vary and depends on factors such as where on the body the sore is located, how severe it is, and how it is being treated. When comparing treatments, most studies usually measure how effective they are by seeing if they reduce the number of new bedsores in a facility rather than how quickly they can heal existing ones.
Still, studies have shown that with 6 months of treatment, sores that are classified as “stage 2” can heal about 70% of the time. Sores that are “stage 3” and “stage 4,” which are more severe, can heal about 50% and 30% of the time, respectively.
In one study that didn’t separate healing rates by stage, about 42% of patients saw their bedsores fully healed after an average of 1.8 years. This study also looked at how often the sores returned based on where they were on the body: 57% of the time for sores on the lower back, 14% for sores on the buttocks, 7% for sores on the outer hip, 7% for sores on the heel, and 14% for sores in other locations.
What can affect how well these sores heal? Predictors include the patient’s age and overall health, the size and severity of the sore, how well the patient is nourished, and whether they have any other chronic illnesses. Interestingly, people who have a higher body mass index and those with higher levels of hemoglobin, a protein that carries oxygen in your blood, tend to have a better healing rate. The same is true for patients who have reconstructive plastic surgery to treat their bedsores.
It is worth noting that treating and preventing bedsores is often a lifelong commitment. Although it can be challenging to study the results of such treatments, the medical community generally agrees that regular prevention and treatment measures are essential for the well-being of these patients.
Possible Complications When Diagnosed with Pressure Ulcer
Decubitus ulcers, also known as bedsores, often lead to complications. The most frequent issue is infection. Serious ulcers, labeled as grade 3 and 4, need thorough medical care because any complications can become life-threatening. Tests on these sores show they contain both kinds of bacteria – those that need oxygen to live (aerobic) and those that don’t (anaerobic). If these bacteria infect deeper tissues and bones, various infections and diseases such as periostitis (inflammation of the tissue around the bone), osteomyelitis (bone infection), septic arthritis (joint infection), and sinus formation can follow. This is particularly dangerous for patients who are already weak, as infection in the blood (septicemia) is very difficult to manage.
These sores cause the body to breakdown (catabolic), leading to severe loss of fluids and proteins. This can cause conditions like low protein levels (hypoproteinemia) or malnutrition. In severe cases, the body can lose up to 50 grams of protein daily because of such an ulcer.
Long-term decubitus ulcers can cause ongoing anemia (low red blood cells) or a condition called secondary amyloidosis. Anemia can also happen due to chronic fluid loss and bleeding from these sores.
If following surgical repair, the care isn’t sufficient, additional complications could arise, including:
- Formation of a hematoma or seroma (blood or serum-filled swelling)
- Wound dehiscence (the wound breaks open)
- Formation of an abscess (pocket of pus)
- Infections in the surgical wound.
This condition is also linked to an increased chance of death. Older patients who have bedsores are 3.6 times more likely to die within 21 months compared to those who don’t. However, some experts argue whether bedsores directly cause death or whether the same underlying health conditions increase both the chance of bedsores and risk of death.
Recovery from Pressure Ulcer
After surgery, it’s important to continue focusing on certain things that could help with recovery. These include:
* Taking pressure off of certain areas
* Keeping the skin clean and in good condition
* Managing any issues with controlling bladder or bowel movements
* Staying healthy through proper nutrition
When the medical team moves patients from the operating table to their specially-designed beds, they need to be careful not to pull or stretch the skin excessively. Patients will be asked to lie flat on their bed for the first 4 weeks. After that time, they will be allowed to position themselves in a half-sitting pose.
Patients aren’t permitted to sit for up to 10 minutes until 6 weeks after the procedure. After these short sitting periods, the surgical area is checked for any color changes or signs that the edges of the wound aren’t holding together. Over the next 2 weeks, patients will be gradually allowed to sit for longer periods, increasing by 10-minute intervals until they can sit for 2 hours at a time. Patients will also be taught how to lift themselves off the bed for 10 seconds every 10 minutes to relieve pressure.
The patient, their family members, and anyone else involved in their care have to all be on the same page with the care plan after surgery. If the patient doesn’t have good support at home, it might be a good idea to consider options such as ongoing care at the hospital or a skilled nursing facility.
Preventing Pressure Ulcer
Patients and their families must understand that stopping the issue from happening again requires effort and responsibility. They should be educated on how to manage the condition both in the hospital and at home. It’s important for them to know the warning signs such as changes in skin color, open sores, fluid draining, bad smell from the sore, and parts of the body that feel numb or have less feeling than normal.
It’s important for patients with bedsores to eat a diet that has enough proteins, vitamins, and minerals. Every 4 hours, patients should move or turn. If they can’t do this themselves, they should ask for help. Patients should use mattresses filled with air or water at home, as using these types of mattresses can notably improve blood flow when resting, how the body reacts after it’s been squeezed tightly, and the normal temperature of the skin. These improvements suggest that using these types of mattresses can improve how well the lining of the blood vessels works.
