Nursing Pressure Sore
What are pressure sores? Pressure sores are areas of injured skin and tissue. They are usually caused by sitting or lying in one position for too long. This puts pressure on certain areas of the body. The pressure can reduce the blood supply to the skin and the tissues under the skin. When a change in position doesn’t occur often enough and the blood supply gets too low, a sore may form. Pressure sores are also called bedsores, pressure ulcers and decubitus ulcers. What are the symptoms of a pressure sore? There are 4 stages of pressure sores. Symptoms at each stage include the following: Stage 1.
The affected skin looks red and may feel warm to the touch. The area may also burn, hurt or itch. In people who have dark skin, the pressure sore may have a blue or purple tint. Stage 2. The affected skin is more damaged in a stage 2 pressure sore, which can result in an open sore that looks like an abrasion or a blister. The skin around the wound may discolored. The area is very painful. Stage 3. These types of pressure sores usually have a crater-like appearance due to increased damage to the tissue below the skin’s surface. This makes the wound deeper. Stage 4.
This is most serious type of pressure sore. The skin and tissue is severely damaged, causing a large wound. Infection can occur at this stage. Muscles, bones, tendons and joints can be affected by stage 4 pressure sores. Who gets pressure sores? Anyone who sits or lies in one position for a long time might get pressure sores. You are more likely to get pressure sores if you are paralyzed, use a wheelchair or spend most of your time in bed. However, even people who are able to walk can develop pressure sores when they must stay in bed because of an illness or an injury.
Some chronic diseases, such as diabetes and hardening of the arteries, make it hard for pressure sores to heal because of poor blood circulation. Peripheral vascular disease,MI, Stroke,Multiple trauma,Musculoskeletal disorders/fractures/contractures,Gibleed , Spinal cord injury (e. g. , decreased sensory perception, muscle spasms),Neurological disorders (e. g. , Guillain-Barre’, multiple sclerosis),Unstable and/or chronic medical conditions (e. g. , diabetes, renal disease, cancer, chronic obstructive pulmonary disease, congestive heart failure),History of previous ressure ulcer,Preterm neonates, Dementia, Recent surgical patient. Where on the body can you get pressure sores? Pressure sores usually develop over bony parts of the body that don’t have much fat to pad them. Pressure sores are most common on the heels and on the hips. Other areas at risk for pressure sores include the base of the spine (tail bone), the shoulder blades, the backs and sides of the knees, and the back of the head. How are pressure sores treated? There are several things you can do to help pressure sores heal: * Relieving the pressure that caused the sore * Treating the sore itself Improving nutrition and other conditions to help the sore heal What can be done to reduce pressure on the sore? Don’t lie on pressure sores. Use foam pads or pillows to take pressure off the sore. Special mattresses, mattress covers, foam wedges or seat cushions can help support you in bed or in a chair to reduce or relieve pressure. Try to avoid resting directly on your hip bone when you’re lying on your side. Use pillows under one side so that your weight rests on the fleshy part of your buttock instead of on your hip bone. Also, use pillows to keep your knees and ankles apart.
When lying on your back, place a pillow under your lower calves to lift your ankles slightly off the bed. When lying in bed, change your position at least every 2 hours. When sitting in a chair or wheelchair, sit upright and straight. An upright, straight position will allow you to move more easily and help prevent new sores. You should change positions every 15 minutes when sitting in a chair or wheelchair. If you cannot move by yourself, have your caregiver help you shift your position. How should the pressure sore be kept clean? In order to heal, pressure sores must be kept clean and free of dead tissue.
Stage 1 sores can be cleaned with mild soap and water. You can clean stage 3 sores by rinsing the area with a salt and water solution. The saltwater removes extra fluid and loose material. Your doctor or nurse can show you how to clean your pressure sore. Pressure sores should be kept covered with a bandage or dressing. Sometimes gauze is used. The gauze is kept moist and must be changed at least once a day. Newer kinds of dressings include a see-through film and a hydrocolloid dressing. A hydrocolloid dressing is a bandage made of a gel that molds to the pressure sore and helps promote healing and skin growth.
These dressings can stay on for several days at a time. Dead tissue (which may look like a scab) in the sore can interfere with healing and lead to infection. There are many ways to remove dead tissue from the pressure sore. Rinsing the sore every time you change the bandage is helpful. Special dressings that help your body dissolve the dead tissue can also be used. They are left in place for several days. Another way to remove dead tissue is to put wet gauze bandages on the sore and allow them to dry. The dead tissue sticks to the gauze and is removed when the gauze is pulled off.
For more severe pressure sores, dead tissue must be removed surgically. Removing dead tissue and cleaning the sore can hurt. Your doctor can suggest a pain reliever for you to take 30 to 60 minutes before your dressing is changed to help reduce pain. Why is good nutrition important for healing sores? Good nutrition is important because it helps your body heal the sore. If you don’t get enough calories, protein and other nutrients (especially vitamin C and zinc, which can help heal wounds like pressure sores), your body won’t be able to heal, no matter how well you care for the pressure sore.
Your doctor, nurse or a dietitian can give you advice about a healthy diet. Be sure to tell your doctor if you have lost or gained weight recently. What if the sore gets infected? Pressure sores that become infected heal more slowly and can spread a dangerous infection to the rest of your body. If you notice any of the signs of infection listed below, call your doctor right away. Signs of an infected pressure sore include the following: * Thick yellow or green pus * A bad smell from the sore * Redness or warmth around the sore * Swelling around the sore * Tenderness around the sore
Signs that the infection may have spread include the following: * Fever * Chills * Mental confusion or difficulty concentrating * Rapid heartbeat * Weakness How are infected pressure sores treated? The treatment of an infected pressure sore depends on how bad the infection is. If only the sore itself is infected, an antibiotic ointment can be put on the sore. When bone or deeper tissue is infected, antibiotics are often required. They can be given intravenously (through a needle put in a vein) or orally (by mouth). How can I tell if the sore is getting better? As a pressure sore heals, it slowly gets smaller.
Less fluid drains from it. New, healthy tissue starts growing at the bottom of the sore. This new tissue is light red or pink and looks lumpy and shiny. It may take 2 to 4 weeks of treatment before you see these signs of healing. How can pressure sores be prevented? The most important step to prevent pressure sores is to avoid prolonged pressure on one part of your body, especially the pressure points mentioned previously. It’s also important to keep your skin healthy. Keep your skin clean and dry. Use a mild soap and warm (not hot) water. Apply moisturizers so your skin doesn’t get too dry.
If you must spend a lot of time in bed or in a wheelchair, check your whole body every day for spots, color changes or other signs of sores. Pay special attention to the pressure points where sores are most likely to occur. If you smoke, you should quit. People who smoke are more likely to develop pressure sores. Exercise can help improve blood flow, strengthen your muscles and improve your overall health. Talk to your doctor if physical activity is hard for you. He or she can suggest exercises that can work for you, or refer you to physical therapist that can help. Pressure Sore Prevention
Relieving pressure: Position must be changed on a regular basis, at least every two hours, and in the very frail at least every hour. Good Diet: A good and balanced diet contributes to healing, as well as avoiding severe nutritional and weight loss Skin Care: Keep the skin clean. Moisture should be minimized. Skin care products should be used that moisturize the skin but do not make it wet or soggy. Use continence aids if a person is unable to control their bladder or bowels. Pads, diapers, convenes or catheterizing. Inspect the skin to see if any redness or breaks in the skin are developing.
Use products to relieve and treat pressure sores; airbeds, foam bed, bed and chair protectors, chair products, continence aids can all contribute to avoiding of bed sores. Clean skin with warm water and minimal friction. Apply lotion often. ————————————————- Avoid direct pressure to bony areas such as ankles and hips. Use pillows and padded protectors to support arms, legs and vulnerable areas. Change the position of a bed-bound person every two hours. Handle and move carefully to avoid skin tears and scrapes.
Change the position of a chair-bound person hourly. Discourage the bed-bound or chair-bound person from sitting with the head elevated more than 30 degrees, except for short periods of time. Check and change bed linens as often as necessary Use continence management products if necessary to reduce exposure to moisture. Padded supports, such as doughnut cushions may, themselves, become a source of pressure. Do not massage bony areas of the body. Do not massage pressure sores. Do not use remedies such as iodine, peroxide and cornstarch that may further irritate the skin.
Pressure sores (bedsores, decubitus ulcers, pressure ulcers) are areas of skin damage resulting from a lack of blood flow due to pressure. • Sores often result from pressure but may also result from pulling on the skin or friction, particularly over bony areas. • The diagnosis is usually based on a physical examination. • Treatment includes cleansing, removal of pressure from the affected area, special dressings, and, sometimes, surgery. Pressure sores can occur in people of any age who are bedbound, chairbound, or unable to reposition themselves. They are more common among older people.
They tend to occur over bony projections where pressure on skin can be concentrated, such as over the hip bones, tailbone, heels, ankles, and elbows. They occur where there is pressure on the skin from a bed, wheelchair, cast, splint, or other hard object . Pressure sores lengthen the time spent in hospitals or nursing homes and increase the cost of care. Pressure sores can be life threatening if they are untreated or if underlying health conditions prevent them from healing. Causes Causes that contribute to the development of pressure sores include: • Pressure Traction • Friction • Moisture • Inadequate nutrition Pressure on skin, especially when over bony areas, reduces or cuts off blood flow to the skin. If blood flow is cut off for more than 1 or 2 hours, the skin dies, beginning with its outer layer (epidermis). The dead skin breaks down and forms an open sore (ulcer). Most people do not develop pressure sores because they constantly shift position without thinking, even when they are asleep. However, some people cannot move normally and are therefore at greater risk of developing pressure sores.
They include people who are paralyzed, comatose, very weak, sedated, or restrained. Paralyzed and comatose people are at particular risk because they also may be unable to move or feel pain (pain normally motivates people to move or to ask to be moved). Traction also reduces blood flow to the skin. Traction occurs when the skin is stretched by being wedged against something or when it sticks to something, often bed linens. When the skin is stretched, the effect is much like pressure. Friction can lead to or worsen pressure sores. Repeated friction may wear away the top layers of skin.
Such skin friction may occur if people are pulled repeatedly across a bed. Moisture can increase skin friction and weaken or damage the protective outer layer of skin if the skin is exposed to it a long time. For example, the skin may be in prolonged contact with perspiration, urine, or feces. Inadequate nutrition increases the risk of developing pressure sores and slows the healing process of sores that do develop. Malnourished people may not have enough body fat to pad the skin and bones or to keep the blood vessels from being squeezed shut.
Also, skin repair is impaired in people whose diets are deficient in protein, vitamin C, or zinc. Did You Know…? • Inadequate nutrition increases the chances of developing pressure sores and slows the healing of sores that do develop. • Repositioning people who cannot move themselves at least every 1 to 2 hours can help prevent pressure sores. Symptoms For most people, pressure sores cause some pain and itching. However, in people whose senses are dulled, even severe sores may be painless. Pressure sores are categorized into four stages according to the severity of damage: • Stage I: Redness and inflammation Stage II: Some shallow skin loss, including abrasions, blisters or both • Stage III: Full-thickness skin loss down to the layer of fat. • Stage IV: Full-thickness skin loss with exposure of underlying muscle, tendon, or bone Pressure sores do not always progress from mild to severe stages. Sometimes the first noticeable sign is a late-stage sore. If pressure sores become infected, they may have an unpleasant odor. Pus may be visible in or around the sore. The area around the pressure sore may become red or feel warm, and pain may worsen if the infection spreads to the surrounding skin (causing cellulitis).
Infection delays healing of shallow sores and can be life threatening in deeper sores. Infection can even penetrate the bone (osteomyelitis), requiring weeks of treatment with antibiotics. In the most severe cases, infection can spread into the bloodstream (sepsis), causing fever or shaking chills. Spotlight on Aging Aging itself does not cause pressure sores. But it causes changes in tissues that make pressure sores more likely to develop. As people age, the outer layers of the skin thin. Many older people have less fat and muscle, which helps absorb pressure.
The number of blood vessels decreases and blood vessels rupture more easily. All wounds, including pressure sores, heal more slowly. Certain conditions make pressure sores more likely to develop: • Being unable to move normally because of a disorder such as stroke • Having to stay in bed for a long time, for example, because of surgery • Being excessively sleepy (such people are less likely to change position or ask someone to reposition them) • Losing sensation because of nerve damage (such people do not feel discomfort or pain, which would prompt them to change ositions) • Becoming less responsive to what is happening in and around them, including their own discomfort or pain, because of a disorder such as dementia Diagnosis Doctors can usually diagnose pressure sores by doing a physical examination. A doctor or nurse usually measures the size and depth of a sore to determine its stage and plan treatment. If the damage is severe, radionuclide bone scanning or gadolinium-enhanced MRI (magnetic resonance imaging) may be done to check whether infection has spread from the sore to bone—a disorder called osteomyelitis.
To diagnose osteomyelitis, doctors may need to take a small sample (biopsy) of bone to see if bacteria grow from it (culture). Prevention Prevention is the best strategy for dealing with pressure sores. In most cases, pressure sores can be prevented by meticulous attention from all caregivers, including nurses, nurses’ aides, and family members. Close daily inspection of a bedridden or chairbound person’s skin can detect early redness or discoloration. Any sign of redness or discoloration at pressure areas is a signal that the person needs to be repositioned and kept from lying or sitting on the discolored area until it returns to normal.
Because shifting position is necessary to keep the blood flowing to the skin, oversedation should be avoided and activity encouraged. People who cannot move themselves should be repositioned every 2 hours if they are in bed and every hour if they are in a chair—more often if possible. The skin must be kept clean and dry because moisture increases the risk of developing pressure sores. Dry skin is less likely to stick to fabrics and cause friction or traction. For people confined to bed, sheets should be changed frequently to make sure they are clean and dry.
Applying noncaking body powder to skin in areas where two parts of the body press against each other (such as the buttocks and groin) can help keep the skin in these areas dry. Bony projections (such as heels and elbows) can be protected with soft materials, such as foam wedges and heel protectors. Donut-shaped devices and sheepskins should be avoided as they only shift pressure or friction from one vulnerable site to another. Special beds, mattresses, and seat cushions can be used to reduce pressure in people who are wheelchair-bound or bedridden.
These products can reduce pressure and offer extra relief. A doctor or nurse can recommend the most appropriate mattress surface or seat cushion. It is important to remember that none of these devices eliminate pressure completely or are a substitute for frequent repositioning. Treatment Treating a pressure sore is much more difficult than preventing one. The main goals of treatment are to relieve pressure on the sores, keep them clean and free of infection, and provide adequate nutrition. Adequate nutrition is important in helping pressure sores heal and in preventing new sores from forming.
A well-balanced, high-protein diet is recommended as well as a daily high-potency vitamin and mineral supplement. Supplemental vitamin C and zinc may help with healing as well. Electrical stimulation, heat therapy, massage therapy, and hyperbaric O2 therapy have not proven helpful. In the earliest stage, pressure sores usually heal by themselves once pressure is removed. When the skin is broken, a doctor or nurse considers the location and condition of the pressure sore when recommending a dressing. Film (see-through) dressings help protect early-stage pressure sores and allow them to heal more quickly.
Hydrocolloid (oxygen- and moisture-retaining) patches protect, keep the skin appropriately moist, and provide a healthy environment for deep sores. Other types of dressings may be used for deeper sores, those that ooze a lot of fluids, and those that are infected. If the sore appears infected or oozes, rinsing with saline and dabbing gently with a gauze pad are helpful. A doctor may need to remove (debride) dead tissue with a scalpel or a chemical solution. Removal of dead tissue is usually painless, because pain is not felt in dead tissue. Some pain may be felt because healthy tissue is nearby.
Health care practitioners may flood (irrigate) the sore, particularly its deep crevices, with a sterile solution to help clean away hidden debris. Sometimes a bed that circulates air (an air-fluidized bed) is used in hospitals and nursing homes. This special bed helps reduce or redistribute pressure on the body. ————————————————- Deep pressure sores are difficult to treat. Sometimes they require skin and muscle flaps, in which healthy, thicker tissue with a good blood supply is surgically repositioned to cover the damaged area.
This type of surgery is not always successful, however, especially for frail older people who are malnourished. Often, when infections develop deep within a sore, antibiotics are given. When bones beneath a sore become infected, the bone infection (osteomyelitis) is extremely difficult to cure and may spread through the bloodstream, requiring many weeks of treatment with an antibiotic (see Bone and Joint Infections: Osteomyelitis). ————————————————- The terms decubitus ulcer and pressure sore often are used interchangeably in the medical community.
Decubitus, from the Latin decumbere, means “to lie down. ” Decubitus ulcer, therefore, does not adequately describe ulceration that occurs in other positions, such as prolonged sitting (eg, the commonly encountered ischial tuberosity ulcer). Because the common denominator of all such ulcerations is pressure, pressure sore is the better term to describe this condition. Pressure is exerted on the skin, soft tissue, muscle, and bone by the weight of an individual against a surface beneath.
These pressures are often in excess of capillary filling pressure, approximately 32 mm Hg. In patients with normal sensitivity, mobility, and mental faculty, pressure sores do not occur. Feedback, conscious and unconscious, from the areas of compression leads inIndividuals who are unable to avoid long periods of uninterrupted pressure over bony prominences—a group of patients that typically includes elderly individuals, persons who are neurologically impaired, and patients who are acutely hospitalized—are at increased risk for the development of necrosis and ulceration.
These individuals cannot protect themselves from the pressure exerted on their body unless they consciously change position or have assistance in doing so. Even the most conscientious patient with an extensive support group and unlimited financial resources may develop ulceration resulting from a brief lapse in avoidance of the ill effects of pressure. [2, 3] dividuals to change body position. These changes shift the pressure prior to any irreversible tissue damage. The inciting event for a pressure sore is compression of the tissues by an external force, such as a mattress, wheelchair pad, or bed rail.
Other traumatic forces that may be present include shear forces and friction. These forces cause microcirculatory occlusion as pressures rise above capillary filling pressure, resulting in ischemia. Ischemia leads to inflammation and tissue anoxia. Tissue anoxia leads to cell death, necrosis, and ulceration. ————————————————- Irreversible changes may occur after as little as 2 hours of uninterrupted preSpecialized support surfaces are available for bedding and wheelchairs, which can maintain tissues at pressures below 30 mm Hgssure. urning and repositioning the patient remain the cornerstones of prevention and treatment. The wound and surrounding skin must be kept clean and free A new international guideline with regard to the prevention of pressure ulcers was released in 2009.  A collaboration between the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel, the guideline covers the latest evidence-based recommendations for all patients in all healthcare settings.
Clinical practice recommendations in regard to prevention will include: * Current definitions and classification of pressure ulcers; * Risk assessment, including the role of nutrition; * Skin inspection and skin care; * Positioning and repositioning patients; * Evidence for use of various support surfaces (air-fluidized beds; alternating air mattresses and cushions; foam-, gel-, or fluid-filled mattresses; overlays for operating tables; turning beds; and other aids for pressure redistribution); * Protective devices used for pressure ulcer prevention; and * Education and training for healthcare providers.