Pressure Ulcers (Decubitus Ulcer)

Pressure Ulcers (Decubitus Ulcer)

The physical manifestation of pathologic alterations in the dermis's blood supply is pressure ulcers. The prevalence of pressure ulcers is highest among elderly people who are bedridden and have spinal cord injuries or cerebrovascular disease. The sacrum, greater trochanter, heels, scapulae, elbows, malleoli, ears, and ischial tuberosities are examples of bone prominences where pressure sores or ulcers can develop.

Grade 3 and 4 pressure ulcers frequently develop into chronic sores, and the patient may even pass away as a result of an ulcer complication (sepsis or osteomyelitis). The aging skin of the elderly person is predisposed to increase vulnerability due to the cumulative effects of impairment due to immobility, nutritional deficiency, chronic deficiency, and chronic diseases involving multiple systems.

Stages of Decubitus Ulcer:

• Stage I:
  • Intact skin with non-branch able redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
• Stage II:
  • Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Present as a shiny or dry shallow ulcer without slough or bruising.
• Stages III:
  • Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss.
• Stage IV:
  • Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis likely to occur.
• Unstageable:
  • Full thickness tissue loss in which actual depth of the ulcer in completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in t5he wound bed.
• Suspected Deep Tissue Injury:
  • A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Contributing factors:

• Immobility
• Aging decreased epidermal thickness, elasticity, and secretion by sebaceous glands.
• Other factors that contribute to the likelihood of development of pressure sores include debility, volume depletion, increases or decreases in body weight, anemia, renal sufficiency, malignant disease, sedation, major surgery, nutritional and vitamin deficiency and various metabolic deficiency).

Treatment:

To treat pressure ulcers, there are strategies including the use of pressure-redistributing support surfaces, nutritional support, repositioning, wound care (e.g. debridement, wound dressings) and biophysical agents (e.g. electrical stimulants).

• Debridment
• Necrotic tissue should be removed in most pressure ulcers. There are five ways to remove necrotic tissue.
  • Autolytic debridement is the use of moist dressings to promote autolysis with the body’s own enzymes and white blood cells.
  • Biological debridement or maggot debridement therapy is the use of the medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria.
  • Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue.
  • Mechanical debridement is the use of debriding dressings, whirlpool or ultrasound for slough in a stable wound.
  • Surgical debridement, or sharp debridement, is the fastest method, as it allows a surgeon to remove quickly remove dead tissue.
• Dressings

Nursing management:

Risk assessment:

• On the admission to acute care:
  • Reassessment intervals whenever the client’s condition changes and based on patient care setting:
    • Based on patient acuity they should be assessed every 24-48 hours in general units.
    • Critically ill patients should be assessed every 12 hours
    • Document risk assessment sores and implement prevention protocols based on overall scores, low subscores and the comprehensive assessment of the other risk factors.
    • Assess risk of surgical patients for increased risk including the following factors: length of operation, a number of hypotensive episodes, and/or low core temperatures intraoperatively, reduced mobility on the first day postoperatively.
• General care Issues and Interventions:
  • Culturally sensitive early assessment for Stage I pressure ulcers in clients with darkly pigmented skin:
    • Use a halogen light to look for skin color changes – may be purple hues or other discoloration based on patient’s skin tone.
    • Compare skin over bony prominences to surrounding skin- may be boggy or stiff or warm or cooler.
• Prevention recommendations
  • Assess skin regularly
    • Clean skin at the time of soiling; avoid hot water and irritating cleaning agents.
    • Use emollients on dry skin.
    • Do not massage bony prominences as a pressure ulcer prevention strategy as well as do not vigorously rub skin at risk for pressure ulcers. Protect skin from moisture associated damage.
    • Use lubricants, protective dressings and proper lifting techniques to avoid skin injury from friction/shear during transferring and turning off clients. Avoid drying out the patient’s skin: use lotion after bathing.
    • Avoid hot water and soaps that are drying when bathing older adults. Use body wash and skin protection.
    • Teach patient, caregivers, and staff the prevention protocol as per hospital policy.
    • Manage moisture by determining the cause; use an absorbent pad that wicks moisture.
    • Protect high-risk areas such as elbows, heels, sacrum and back of the head from friction injury.
  • Repositioning and support surface
    • Keep patients off the reddened areas of skin.
    • Repositioning schedules are individualized based on the patient’s condition, care goals, vulnerable skin areas, and type of support surface being used. Communicate the repositioning schedule to all patient’s caregivers.
    • Raise heels of bed bound clients off the bed; do not use donut types devices
    • Turn and position bed bound clients every 2 hours if consistent with overall care goals.
    • Use a written schedule for turning and repositioning clients.
    • Use pillows or other devices to keep bony prominences from direct contact with each other.
    • Use a 30 degree tilted side lying position; do not place clients directly in a 90-degree side lying position on their trochanter.
    • Keep the head of the bed at lowest height possible.
    • Use transfer and lifting devices to move clients rather than dragging them in bed during transfers and position changes.
    • Use pressure reducing devices (static air, alternating gel or water mattresses)
    • Keep patient as active as possible: encourage mobilization.
    • Avoid positioning the patient directly on his or her trochanter.
    • Manage friction and shear.
• Nutrition
  • Assess nutritional support of patients at risk for pressure ulcers.
  • For at-risk patients, follow nutritional guidelines for hydration (1ml/kcal of fluid per day) and calories (30-35 kcal/kg of body weights per day), protein 1.25-1.5 g/kg per day). Give high protein supplements or tube feelings in addition to the usual diet in persons at nutritional and pressure ulcers.
  • Manage nutrition. Consult a dietician and correct nutritional deficiencies by increasing protein and calorie intake A,C and E vitamin supplements as needed.

Other nursing care:

• Help the elderly exercise regularly.
• Try to make sure that the person eats to well-balanced diet, with plenty of protein and fresh fruits and vegetables.
• If the person has problems with incontinence, male sure they don’t stay in wet clothes or wet bed.
• Excessive heat and moisture can contribute to pressure ulcers, so try not to let the person become hot and sweaty.
• Avoid close fitting clothing or tight bedding, especially over the feet.
• Never rub or massage any places where the skin has reddened, as this could cause further damage.