What Are Pressure Ulcers?

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A pressure ulcer is an area of skin that breaks down when constant pressure is placed against the skin, or pressure in combination with shear and/or friction. This skin breakdown can ultimately result in the exposure of the underlying tissue, including bone.

Pressure ulcers usually occur over a bony prominence, such as the sacrum (tail bone), hip bone, elbow, or ischium.​ They are treated with a variety of wound care methods but may result in the need for plastic surgery. Prevention of pressure ulcers is an area of emphasis for nursing, and an indicator of the quality of nursing care. Alternative names include pressure injury (now the preferred term), pressure sore, decubitus ulcer, decubiti, and bedsore.

The National Pressure Ulcer Advisory Panel (NPUAP) initiated using the term pressure injury rather than pressure ulcer in 2016. This change is due to the injury beginning before there is a break in the skin (ulcer). The staging of pressure injuries was also modified at that time.

Types of Pressure Ulcers

Pressure injuries are classified according to stages describing the symptoms and the amount of tissue loss. Different classification systems have been used over the years. The staging system revised in 2016 by NPUAP describes these symptoms and stages:

  • Stage 1: Intact skin with persistent redness (erythema) of a localized area. When pressed, the area doesn't blanch (lighten, then darken again when the pressure is released). If the person has darkly pigmented skin (in which redness may be harder to note), it may differ in color from the surrounding area. Note that before these changes are evident, there may be branch able erythema, changes in temperature, firmness, or sensation. If the color change is to purple or maroon, this indicates a more severe deep pressure injury.
  • Stage 2: Partial-thickness skin loss with exposed dermis. The wound looks like a shallow open ulcer or an intact or ruptured blister. The bed of the wound is still pink, red, and moist, indicating it is viable. You don't see eschar (scab), granulation tissue (growth of healing skin that is pink or red and uneven), or slough (soft, moist tissue that adheres to the wound bed in string or clumps).
  • Stage 3: Full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Often you will see granulation tissue and rolled edges of the wound. There may be slough or eschar.
  • Stage 4: Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle. The wound may have slough, eschar, rolled edges, undermining, or tunneling.
  • Unstageable pressure injury: A stage 3 or 4 full-thickness injury that is obscured by slough or eschar. Stable eschar should not be removed on a limb or heel.
  • Deep tissue pressure injury: Intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation that reveals a dark wound bed or blood-filled blister.

Pressure Ulcer Symptoms

Those who are at risk of pressure ulcers are typically checked by their caregivers frequently to look for the symptoms of pressure injury.

Signs to look for include:

  • Changes in skin color. In people with light skin tones, look for redness that doesn't blanch (get lighter) when you press lightly on it. In people with darker skin tones, look for darker areas of skin that don't lighten when you press lightly on them.
  • Swelling, pain, or tenderness
  • Areas of skin that feel warmer or cooler than the surrounding areas
  • An open ulcer or blister
  • Pus-like drainage

Sites

A pressure ulcer can occur anywhere prolonged pressure is applied. However, the most common susceptible areas are bony prominences. A report of the California Hospital Patient Safety Organization (CHPSO) found these the most frequent locations for healthcare-acquired pressure injuries, from most to least:

  • Coccyx
  • Sacrum
  • Heel
  • Ear
  • Buttocks
  • Ankle
  • Nose
  • Gluteal cleft

Causes

Skin breakdown is caused by sustained pressures on the skin. The increased pressure narrows or collapses blood vessels, which decreases blood flow to the skin and underlying tissues. This ultimately leads to tissue death.

Having poor skin hygiene, lying on hard surfaces, use of patient restraints, or having poor-fitting prostheses are extrinsic risk factors. Underlying (intrinsic) risk factors include prolonged immobility, diabetes, smoking, poor nutrition, vascular disease, spinal cord injury, contractures, and immunosuppression.

Pressure injuries may also result from medical devices. These can include bilevel noninvasive positive pressure breathing masks, endotracheal tubes, nasogastric tubes, and nasal oxygen cannula tubing.

High-Risk Populations for Pressure Ulcers

The highest incidences of pressure ulcers are found in the following populations:

  • Elderly
  • Those with hip fractures and other fractures
  • Quadriplegic
  • Neurologically-impaired young (children with paralysis, spina bifida, brain injury, etc.)
  • Chronically hospitalized
  • Nursing home residents

Diagnosis

When a pressure injury is suspected, a healthcare provider should assess it by location, size, appearance, color changes, the state of the base tissues and edges, pain, odor, and exudate. The provider will especially look for signs of infection.

The provider will look for edema, check the distal pulses, and check for signs of neuropathy (such as with a monofilament exam).

Diagnostic tests may include ankle-brachial index, pulse volume recording, Doppler waveforms, and ultrasound imaging for venous disease.

The provider can then stage the ulcer and determine appropriate treatment and monitoring.

Treatment

Pressure ulcers are managed both medically and/or surgically.

Stage 1 and 2 pressure ulcers can be managed without surgery. The wound is cleaned and then kept clean, moist, and covered with an appropriate dressing. Frequent dressing changes are used to keep the wound clean and fight off bacteria. Sometimes, topical antibiotic medications are used on the pressure ulcer as well.

Stage 3 and 4 pressure ulcers frequently require surgical intervention. The first step is to remove all the dead tissue, known as debridement. It can be done in several ways. These include the use of ultrasound, irrigation, laser, biosurgery (using maggots), surgery, and topical methods (such as medical-grade honey or enzyme ointments). Debridement of the pressure ulcer is followed by flap reconstruction. Flap reconstruction involves using your own tissue to fill the hole/ulcer

Complications of pressure ulcers may include:

  • Hematoma
  • Infection
  • Wound dehiscence (the edges of the wounds do not meet)
  • Recurrence

Prevention

Pressure ulcers are preventable. Here are some tips on how you can avoid them.

  • Minimize moisture to avoid skin maceration and breakdown. Avoid prolonged contact with feces, urine, or sweat.
  • Use caution when transferring to and from your bed or a chair. This avoids friction and shearing of the skin.
  • Avoid sitting or lying in one position for a prolonged period of time. Switching positions gives your skin a break and allows the return of blood flow.
  • In bed, relieve pressure on bony parts of your body by using pillows or foam wedges.
  • Maintain proper nutrition. Eating a healthy diet keeps your skin healthy and improves its ability to avoid injury and fight infection.

Hospital-acquired pressure injuries have been significantly reduced due to efforts made by the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality. The rate fell from 40.3 to 30.9 per 1,000 discharges from 2010 to 2014. The more serious stage 3 and 4 injuries dropeed from 11.8 to 0.8 cases per 1,000 patients from 2008 to 2012.

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