Causes Of Pressure Ulcers
Pressure ulcers are caused by sustained pressure being placed on a particular part of the body.
This pressure interrupts the blood supply to the affected area of skin. Blood contains oxygen and other nutrients that are needed to help keep tissue healthy. Without a constant blood supply, tissue is damaged and will eventually die.
The lack of blood supply also means that the skin no longer receives infection-fighting white blood cells. Once an ulcer has developed, it can become infected by bacteria.
People with normal mobility do not develop pressure ulcers, as their body automatically makes hundreds of regular movements that prevent pressure building up on any part of their body.
For example, you may think that you are lying still when asleep, but you may shift position up to 20 times a night.
Pressure ulcers can be caused by:
- pressure from a hard surface such as a bed or wheelchair
- pressure that is placed on the skin through involuntary muscle movements such as muscle spasms
- moisture which can break down the outer layer of the skin
The time it takes for a pressure ulcer to form will depend on:
- the amount of pressure
- how vulnerable a persons skin is to damage
Grade 3 or 4 pressure ulcers can develop quickly. For example, in susceptible people, a full-thickness pressure ulcer can sometimes develop in just 1 or 2 hours. However, in some cases, the damage will only become apparent a few days after the injury has occurred.
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Caregivers might sometimes provide too much help. For instance, they might turn someone over in bed although the person is actually still capable of turning over in bed themselves, perhaps with just a little assistance. It is better to only help as much as needed, so the person stays as independent as possible, helping to prevent pressure ulcers.
If you are caring for a family member at home or go to visit them in the hospital or at a nursing home, you can help them move short distances, for instance when taking a few steps to the table to sit down and eat.
If someone needs to lie in bed for a long time, a nursing care plan is usually made together with nursing professionals. This may include information such as how many times a day a person needs to be repositioned. It is important for everyone to make sure that the plan is followed properly. This also includes regularly changing diapers or incontinence pads.
You should tell the nurses or doctors immediately about any red or sore areas of skin. They can then take a closer look at the affected area. It is always important to take pressure off that part of your body.
Spilsbury K, Nelson A, Cullum N, Iglesias C, Nixon J, Mason S. Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs 2007 57: 494-504.
IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.
Causes And Prevention Of Pressure Sores
Pressure sores are wounds that develop when constant pressure or friction on one area of the body damages the skin. Constant pressure on an area of skin stops blood flowing normally, so the cells die and the skin breaks down.
Other names for pressure sores are bedsores, pressure ulcers and decubitus ulcers.
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When You Are In Bed
Use a foam mattress or one that is filled with gel or air. Place pads under your bottom to absorb wetness to help keep your skin dry.
Use a soft pillow or a piece of soft foam between parts of your body that press against each other or against your mattress.
When you are lying on your side, put a pillow or foam between your knees and ankles.
When you are lying on your back, put a pillow or foam:
- Under your heels. Or, place a pillow under your calves to lift up your heels, another way to relieve pressure on your heels.
- Under your tailbone area.
- Under your shoulders and shoulder blades.
- Under your elbows.
Other tips are:
- DO NOT put pillows under your knees. It puts pressure on your heels.
- Never drag yourself to change your position or get in or out of bed. Dragging causes skin breakdown. Get help if you need moving in bed or getting in or out of bed.
- If someone else moves you, they should lift you or use a draw sheet to move you.
- Change your position every 1 to 2 hours to keep the pressure off any one spot.
- Sheets and clothing should be dry and smooth, with no wrinkles.
- Remove any objects such as pins, pencils or pens, or coins from your bed.
- DO NOT raise the head of your bed to more than a 30 degree angle. Being flatter keeps your body from sliding down. Sliding may harm your skin.
- Check your skin often for any areas of skin breakdown.
Incidence Mortality And Costs
The incidence rates of pressure ulcers vary greatly with the health care settings. The National Pressure Ulcer Advisory Panel says the incidence ranges from 0.4 percent to 38 percent in hospitals, from 2.2 percent to 23.9 percent in skilled nursing facilities, and from 0 percent to 17 percent for home health agencies. There is ample evidence that the majority of pressure ulcers occur relatively early in the admissions process. For patients in the hospital, they can occur within the first 2 weeks. With the increased acuity of elderly patients admitted and decreased lengths of stay in hospital, new data suggest that 15 percent of elderly patients will develop pressure ulcers within the first week of hospitalization. For those elderly residents admitted to long-term care, pressure ulcers are most likely to develop within the first 4 weeks of admission.
Mortality is also associated with pressure ulcers. Several studies noted mortality rates as high as 60 percent for older persons with pressure ulcers within 1 year of hospital discharge., Most often, pressure ulcers do not cause death rather the pressure ulcer develops after a sequential decline in health status. Thus, the development of pressure ulcers can be a predictor of mortality. Studies further suggested that the development of skin breakdown postsurgery can lead elders to have major functional impairment post surgical procedure.
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How To Prevent Pressure Ulcers
Pressure ulcers are preventable if an experienced caregiver or nurse properly inspects skin for areas of redness. If someone you love is at risk for bed sores, consider the following:
- Change position and turn every two hours
- Place soft padding in a wheelchair or bed to reduce pressure.
- Keep skin clean and dry.
- Get enough fluids, protein, minerals, and vitamins.
Consider the following tips for skin care:
- When washing the skin, use a mild cleanser and then dry the skin thoroughly. Try to do this cleansing routine regularly.
- Use a good moisturizer to protect your skin from urine and feces.
- Change bedding and clothes frequently. Beware of buttons and folds of bedding as they can irritate the skin.
- Examine your skin daily for warning signs of pressure ulcers.
Why It Is Important To Do This Review
Research indicates that pressure ulcers represent a major burden of sickness and reduced quality of life for patients, their carers , and their families . Often patients who develop pressure ulcers require prolonged and frequent contact with the healthcare system and suffer much pain , discomfort and inconvenience .
The presence of a pressure ulcer creates a number of significant difficulties psychologically, physically and clinically to patients, carers and their families. Clinicians, working in a variety of clinical and nonclinical settings, including primary care and acute trusts, also face challenges when providing holistic, personcentred services for the assessment and treatment of pressure ulcers. These challenges include clinical decisions regarding methods of assessment, and which treatments to use on individuals with an existing pressure ulcer.
Healthcare professionals attempt to reduce the incidence of severe pressure ulcers by the identification of people at high risk, and the use of preventative strategies, such as the deployment of pressurerelieving equipment. It is essential that initiatives are based on the best available clinical and costeffectiveness evidence, and we have, therefore, undertaken a systematic review of the evidence for the effectiveness of pressurerelieving support surfaces such as beds, mattresses, cushions, and repositioning interventions.
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The Importance Of Pressure Ulcer Prevention
Pressure ulcers are caused if the blood supply to the skin and the underlying tissues is compromised for prolonged periods of time due to mechanical compression of the local vasulature, with ensuing hypoxia and tissue necrosis. Most of the time, pressure ulcers significantly impact the patients morbidity, mortality and quality of life.
In some cases, these occur quickly – between the first hour and 4 to 6 hours after sustained loading.
Depending on population and ulcer grade, up to 50 percent of pressure injuries can be avoided.
Furthermore, research has proven that the costs of pressure ulcer treatment exceed those of prevention by 2.5 times.
How Can Friends And Family Help
Caregivers might sometimes provide too much help. For instance, they might turn someone over in bed although the person is actually still capable of turning over in bed themselves, perhaps with just a little assistance. It is better to only help as much as needed, so the person stays as independent as possible, helping to prevent pressure ulcers.
If you are caring for a family member at home or go to visit them in the hospital or at a nursing home, you can help them move short distances, for instance when taking a few steps to the table to sit down and eat.
If someone needs to lie in bed for a long time, a nursing care plan is usually made together with nursing professionals. This may include information such as how many times a day a person needs to be repositioned. It is important for everyone to make sure that the plan is followed properly. This also includes regularly changing diapers or incontinence pads.
You should tell the nurses or doctors immediately about any red or sore areas of skin. They can then take a closer look at the affected area. It is always important to take pressure off that part of your body.
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Why Pressure Ulcer/injury Prevention Is Critical
Pressure injuries are very common in hospitals and long-term care facilities. In one recent survey, it was found that 26.7% of patients in a hospital had pressure injuries.2 The high rate of pressure injuries equates to significant time and resources spent on care and treatment. Some estimates place the cost of pressure injury treatment in the United States as high as $11.6 billion each year. This makes pressure injuries one of the most costly medical conditions.3 To reduce these costs and improve patient outcomes, it is important for nurses and other health care professionals to take a proactive approach focused on pressure injury prevention.
Interested in more information on pressure injury prevention?
About the Sponsor:For over 155 years, Smith & Nephew has provided innovative solutions that help reduce the human and economic costs of wounds and help people regain their lives.
Special Devices That Can Help You
In addition to turning and repositioning frequently, using a special surface to reduce or relieve pressure can help a great deal. The simplest of these is an egg crate mattress. Many hospice and home health agencies provide these free of charge but they are relatively inexpensive at your local department store.
If your loved one is spending a lot of time up in a chair, egg crate chair pads are also available. An egg crate surface helps distribute pressure more evenly, helping minimize the amount of pressure on one area.
A step up from the egg crate mattress is an air mattress overlay. This type of surface is placed on top of a mattress and typically alternates air pressure in various columns. When using an egg crate mattress or an air mattress overlay, its still important to maintain the turning schedule. These devices dont replace frequent repositioning.
The big guns of pressure-relieving devices are the fluidized air mattresses. These special mattresses contain silicone-coated glass beads that become fluid when the air is pumped through them. These mattresses do a wonderful job of relieving pressure but they have their downside.
The frame of the mattress makes transferring to and from bed difficult. And if the person wants to sit up in bed, a foam wedge would probably need to be used to help support their back. This mattress is really best suited for palliative care patients who are fully bed-bound, have severe pressure ulcers, and are in a lot of pain.
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What Is A Pressure Ulcer
A pressure ulcer is an area of damage to the skin and underlying tissue. They are also known as pressure sores or bed sores. They are usually caused by sitting or lying in one position without moving over a period of time. A pressure ulcer can develop very quickly over a few hours, especially if you are ill.
The first sign that a pressure ulcer may be developing is that your skin will start to change colour. It may appear slightly red or darker than usual and does not fade when pressure is removed. In some cases it can appear purple or maroon and can be confused as a bruise.
In people with darker skin tones, it is not easy to see a reddened/purple area. In this case, it is best to check by touching areas of the body that are at risk from pressure ulcers . The area may also feel warmer or cooler to touch, firmer or spongy or swollen.
Our nurses are responsible for preventing pressure ulcers. Your help in detecting the early signs of an ulcer can alert our staff, helping prevent pressure ulcers getting worse.If the early signs of a pressure ulcer are not treated quickly, it can develop into an open blister, which can then lead to a more serious pressure ulcer.
If you notice any signs of pressure damage, you must notify a healthcare professional immediately.
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Pressure ulcers usually heal very slowly, and may come back. That’s why it’s so important to make sure they don’t develop in the first place. People who are confined to a wheelchair or have to stay in bed for a long time often say that they can feel parts of their body becoming sore. It’s important to pay attention to what they say, to quickly reduce pressure on their skin, and regularly change the position they sit or lie in.
Observing which parts of the body are most susceptible to pressure, as well as the positions that put the most pressure on them, can help you get an idea of what sort of relief might be helpful. For example, lying down puts much less pressure on your backside than sitting in a chair. If you use a wheelchair, you can find out what helps to reduce the pressure and then make that your routine.
It’s also important to try to move if possible even if you have to lie in bed or sit in a wheelchair. If you are able to sit up, leave the bed, or even walk a few steps with a bit of help, its a good idea to do that as often as possible.
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Even though it’s often recommended that people be repositioned every two hours, there’s no single recommendation that works for everyone. Some people can lie in the same position for quite a long time without getting ulcers, while others need to switch much more often. Research has not yet found out how often someone should change position to get the best preventive effect.
Unnecessarily moving someone too much for no good reason can also have disadvantages. For instance, repositioning every two hours at night may wake the person each time and keep them from getting a good nights sleep. Changing position can also be very painful for people who have wounds or joint conditions. Frequent repositioning is physically demanding for caregivers or family members too. It’s therefore important to observe how often someones position really needs to be shifted. It can then help to make a note every time they are repositioned.
Where To Find Further Information
If you require further information regarding pressure ulcer prevention or treatment, please ask your nurse, doctor or any member of the team.
Adapted from guidelines produced by the National Institute for Clinical Excellence . You can download further information from www.nice.org.uk
The Tissue Viability Team are available to offer advice and can be contacted Monday to Friday 8.00am 4.00pm on Telephone No: 674239.
Answerphone is available outside of these times and messages will be answered as soon as possible.
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Phases Of Wound Healing
The first phase of wound healing is hemostasis. Briefly, in this phase, damaged blood vessels are sealed when platelets form a stable clot to seal the blood vessel. The platelets also stimulate the clotting cascade through the production of thrombin that initiates the production of fibrin. The fibrin mesh ultimately strengthens the platelet aggregate into a hemostatic plug. Hemostasis occurs within minutes of injury unless the injured individual has underlying clotting disorders .
In the second phase of wound healing, the inflammation phase, the erythema, swelling and warmth that occur are often associated with pain. This phase of wound healing usually lasts up to 4 days after injury. During this phase, neutrophils or PMN’s and plasma are leaked from the blood vessels into the surrounding tissue. These factors clean debris from the surrounding tissue and provide the first line of defence against infection. Macrophages are also active in the second phase of wound healing acting to destroy bacteria and secreting growth factors which direct the third phase of wound healing.
In the final phase of wound healing, maturation, remodeling of the dermal layer occurs to produce greater tensile strength. The cells that are involved in this process are fibroblasts. This process can take up to 2 years to complete .