Pressure Ulcers
Quick Reference
Reviewed by Dr. Keith Harding
Pressure ulcers, or decubitus, are areas of damaged skin caused by prolonged pressure of certain bones against the skin. Pressure ulcers are commonly called bedsores, as they most often affect people confined to a bed or chair. Pressure ulcers can be superficial or very deep and vary in appearance.
Pressure ulcers form where bones cause the greatest force on the skin. The areas most associated with pressure ulcers are the tailbone, heels, elbows, shoulder blades, knees, ankles, the back of the head, and the spine. Constant pressure on the skin squeezes tiny blood vessels and prevents them from carrying nutrients and oxygen to the skin. As a result, the tissue dies and a pressure ulcer forms.
A pressure ulcer can take as little as one to two hours to form. In the early stages, pressure ulcers may appear as nothing more than a redness of the skin. But over time, the redness may progress to a deep opening in the skin. In the worst cases, these sores penetrate through the muscle and fat tissue, all the way down to the bones. Pressure ulcers may be extremely painful, and can lead to secondary infection and even death. It is important if you are immobile or confined to a bed or chair to take the necessary steps to prevent pressure ulcers from developing.
One of the challenges in pressure ulcers is that sometimes, the damage occurs to the underlying structures of the skin and body tissue before appearing on the outside of the skin. Pressure damage often occurs before it is visible.
Detailed Description
Approximately one in ten hospital patients, one in eight home care patients, and one in four nursing home residents suffer from pressure ulcers. Several factors result in an increased risk of pressure ulcers. Anyone who is confined to a bed, chair or wheelchair has an elevated risk. Prevention tips for bed-bound individuals:
Change position at least every two hours.
If you cannot change position yourself, make sure your caregiver uses lifting devices instead of dragging you to change your position. Dragging causes friction that can injure skin.
Use pillows or foam wedges to keep knees and ankles from direct contact with each other.
Use a special mattress with foam, air, gel or water, designed to prevent pressure ulcers.
Raise the head of the bed as little as possible. When it is raised more than 30 degrees, the skin may slide over the surface, which can damage the skin and blood vessels.
Spread weight as evenly as possible. When it is raised more than 30 degrees, the skin may slide over the surface, which can damage the skin and blood vessels.
Spread weight as evenly as possible. Avoid lying directly on hipbone when lying on your side. Support pillows may help.
Pillows can be placed under legs between mid-calf and ankle to keep heels off bed. Do not place pillows behind the knee.
Wash skin properly, as designated in the following section.
Prevention tips for chair-bound individuals:
If you can change positions without help, try to do so every 15 minutes. If not, change position every hour. The increased frequency is necessary because sitting places more pressure on the skin than lying in a bed does.
If you cannot change positions without help, make sure your caregiver uses lifting devices instead of dragging you to change your position. Again, dragging causes friction that can injure skin.
Use foam, gel or air cushions to relieve pressure.
Avoid donut-shaped cushions. They reduce blood flow and cause tissue to swell, which increases risk of developing sores.
Maintain good posture and comfort.
Wash skin properly, as designated in the following section.
People who are unable to move due to paralysis, coma or hip fracture are at high risk to suffer from pressure ulcers. Incontinence can affect your chances as well, as moisture can irritate the skin. If possible, treat the root cause of incontinence (i.e., urinary tract infections, some medications, etc).
Prevention tips for those with incontinence:
Wear soft, absorbent material with a quick-drying surface to minimize contact between urine or fecal matter and skin.
Clean skin as soon as it is soiled.
You or your caregiver should inspect skin at least once per day to identify problem areas before they become serious. Pay special attention to pressure points and reddened areas that do not fade after you change position. You can use a mirror for hard-to-see areas.
Use a soft sponge or cloth to reduce friction.
Bathe with warm water and mild soap. Avoid moisturizers or soap with alcohol.
Keep skin moist with cream or oil, but minimize moisture from wounds, urine, stool or sweat.
Avoid cold or dry air.
You can use special ointments to protect skin from unwanted moisture. A thin layer of cornstarch can reduce friction damage.
Poor nutrition also increases the likelihood of pressure ulcers, as it weakens the skin. Healthy eating means healthier skin and circulation. Eat a balanced diet if at all possible. If not, talk to your health care provider about nutrition supplements. Protein and calories are particularly important. Those with peripheral vascular disease - a restriction of blood flow in any part of the body except the heart - are also at higher risk for bedsores. This disease should be treated directly, but some tips to avoid pressure ulcers include rehabilitation programs and communicating openly with your health care provider about your needs, wants and concerns. Your participation in maintaining your comfort is crucial. Finally, people who suffer from lowered mental awareness are also susceptible, as they may lack the alertness to change sitting positions to relieve pressure at the necessary frequency.
Treatment
Constant vigilance in monitoring the rotation of body pressure among people who are confined to beds and chairs is the most important factor in treating pressure ulcers. For the bedridden immobile, positions should generally be changed at least once every two hours. Keep the head of the bed as low as possible in order to prevent sliding, which pulls at the skin. Do not vigorously rub or massage reddened bony prominences, as this may contribute to blood vessel damage below the surface. Avoid lying directly on the hipbone or placing a pillow behind the knees. Finally, keep pillows between the patient’s knees and ankles to prevent them from rubbing against each other, and place a pillow under the calves, to keep the heels elevated.
For the immobile person confined to a chair, more frequent position changes may be helpful and for those persons able to move themselves, frequent changes and weight shifts are recommended. Lift, rather than drag the patient, as dragging can damage the surface of the skin by bending or stretching the underlying blood vessels. Finally, avoid using donut-ring cushions as they increase pressure on parts of the buttocks.
There are a variety of mattresses and support surfaces to help reduce pressure over bony prominences in the body. These include mattresses of foam, water, gel, and air that can go on top of a regular mattress of replace it entirely. Additionally full bed replacements exist that reduce pressure even further. An example is the air-fluidized bed, that circulates air throughout the mattress and creates an even distribution of body weight.
Advances in wound care management have introduced the concept of moist wound healing, to the overall treatment of wounds. Moist wound healing encompasses the use of protective coverings and gels that foster the protection of the wound, along with the maintenance of moisture in the environment. A moist wound bed promotes active healing, and allows skin cells to move across the wound bed and adhere to one another. Moist wound healing methods are effective in treating pressure ulcers.
Proper skin care is of utmost importance in preventing pressure ulcers. Inspect the skin often, and pay special attention to the bony pressure points. Notice reddened areas that remain after changing position and removing pressure. Make sure the skin stays clean and dry, and always clean the skin immediately after soiling. Use warm water, mild soap, and a gentle washcloth for bathing the skin, and apply creams or oils to over dried skin. When possible, treat incontinence, and if it cannot be prevented, use pads or briefs that absorb urine and wick moisture away from the skin. For the person who is consistently incontinent, routine use of protective ointment helps prevent maceration and irritation. Incontinence cleansers exist that help maintain the natural chemistry of the skin.
Last updated: 16-Nov-00
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