Pressure
Sores - (syn. Bed sores, Decubitus ulcer)
Definition
Pressure sores are wounds that occur from tissue breakdown
as a result of unrelieved pressure over a particular body
site. Pressure sores typically occur over underlying bony
prominences when an individual lies or sits for long periods
of time. The important factor in the development of these
sores is unrelieved pressure. Pressure sores typically occur
over the base of the spine, the hip, the heel, the back
of the head and back. Pressure sores may also occur over
the bony promiences of the buttocks (ischial tuberosities).
The severity of a pressure sore is graded into four
stages:
Stage 1: With
these pressure sores, the skin is intact but remains red
for more than one hour after release of pressure.
Stage 2: These
sores have blistering or ulceration of the skin with or
without infection.
Stage 3: These
pressure sores have destruction of the skin and underlying
fat with tissue loss into the muscle. Infection may be present.
Stage 4: These
pressure sores are the most serious and such sores involve
the underlying bone or joint; infection may be present.
Incidence / Age
The incidence of pressure sores is highly variable depending
upon the population evaluated. Typical studies suggest that
approximately 10% of the general hospital population will
have a pressure at any one time. Pressure sores may affect
individuals of any age but they are more common in older
patients.
The major factor underlying the development of pressure
sores is unrelieved pressure. In addition shearing forces
loss of feeling, incontinence, exposure to moisture, loss
of mobility and friction may all contribute to the development
of pressure sores. Individually any one of these factors
does not produce a pressure sore but does so in combination
with unrelieved pressure.
These patient groups are commonly at risk of developing
pressure sores: 1, patients with neurological illnesses;
2, the elderly and 3, the hospitalised. Pressure sores are
associated with medical problems such as heart disease,
neurological disease and bone and joint injuries. Increasing
age is an associated factor for pressure sores and in one
study over 60% of patients with pressure sores were more
than 70 years of age. Other factors associated with the
developments of pressure sores are strokes, being bed or
chair bound and impaired nutritional intake. In addition,
patients who are chronically ill and debilitated frequently
have nutritional deficiencies.
The early sign of a pressure sore is redness of the skin
that persists following the release of pressure. Should
the pressure continue, say beyond 2-6 hours, blistering
and ulceration of the skin may appear. Should the pressure
continue further death of the underlying fat will occur,
typically after about 6 hours of relieved pressure. At this
stage the skin may appear blue and firm to touch. Full thickness
tissue loss with extensive destruction, exposing bone and
joints is the next stage and this will develop should pressure
relief not be instituted.
Forces such as shear and friction rather than direct pressure
may produce the early signs of pressure sore formation.
Prolonged, unrelieved direct pressure typically results
in tissue loss with ulcer formation. These ulcers often
demonstrate an iceberg phenomenon. That means the skin wound
is only the "tip of the iceberg" and there may
be a large associated underlying wound. The size of the
underlying wound is often not appreciated by the patient
or their carers. Pressure sores may smell offensive and
may develop serious wound infections.
Complications of disorder
Chronic wounds such as pressure sores may get infected.
Pressure sores may expose vital internal structures such
as joints.
Tests
Simple blood counts are commonly requested in patients with
pressure sores. Such tests are necessary to rule out the
presence of anaemia and poor nutritional states. Other tests
may be necessary depending upon associated conditions that
the patient may have.
Treatment
Pressure sores are due to many inter-related factors; as
with many such disease processes - a multidisciplinary approach
to treatment is preferred. Many individuals are involved
in the management of patients with pressure sores and this
would include the general practitioner, community nurses,
dieticians, hospital physicians and reconstructive surgeons.
Medical -
Some pressure sores may heal spontaneously without surgical
treatment so long as the wound is thoroughly cleaned and
pressure on the area is at worst minimised and at best avoided.
Healing of a pressure sore in these circumstances requires
the control of infection and removal of any dead tissue,
avoidance of pressure and appropriate wound care.
It is important to determine the underlying course of the
pressure and if possible to correct this or minimise its
impact. Appropriate nursing care and the use of pressure
releasing mattresses and aids should be used to alleviate
pressure. If moisture is a problem, means to control incontinence
or excess sweating should be provided. Dirty wounds should
be cleaned by regular dressing and if necessary by surgical
removal of dead tissue. Some wound dressing products may
help the removal of dead tissue. The patient's nutrition
should be looked at and malnourished patients should be
given appropriate dietary advice and dietary supplementation
where necessary. High protein diets are helpful and iron
supplements may be necessary if the patient is anaemic.
Vitamin supplementation, with vitamin A & C, may occasionally
be necessary.
Surgical -
Unfortunately a significant proportion of patients with
pressure sores will not respond to non-surgical treatments.
The principle of treatment of a pressure sore is; 1, the
pressure sore is cut away back to healthy tissue; 2, underlying
bone is partially or completely removed to reduce the bony
prominences; 3, the wound is closed with healthy tissue
that is durable and can provide good padding over the bony
prominence. This healthy tissue is usually moved from next
to the pressure sore and is known as a flap.
Prior to performing surgery for pressure sores it is important
that any associated risk factors are dealt with. These have
been detailed above. In patients with chronic conditions
who will remain at risk of pressure sores following any
corrective surgery it is important that preventative measures
are put in place to prevent the pressure sore from recurring.
Outcome
Patients who develop pressure sores as part of an acute
illness, without any chronic component, have a good prognosis
for recovery from their pressure sores. However, many patients
are not in this category and most patients who develop pressure
sores remain debilitated and at risk following surgery.
Following pressure sore surgery initial cure rates are good
(80-90%), However, recurrence following pressure sore surgery
is common. The incidence of recurrence is very varied (13-69%).
