What is Pressure Ulcer?
Pressure ulcers mainly affect people who have long periods of rest due to their old age, illness or paralysis. This situation favors the development of ulcerous lesions in the parts of the body that press against a surface.
A pressure ulcer may appear when the area of the skin is subjected to a pressure for a long time and there is no displacement to relieve the position of the body. All parts of the body that are not protected by muscles or fatty tissue against the pressure produced by the position may develop decumbent ulcers: Sacral region, the heels, the minor trochanter of the femur and the ankles. If preventive measures are not taken in patients at high risk of pressure ulcer, the affected areas redden and evolve to lesions with blisters. As a result, the tissue becomes necrotic. A pressure ulcer can deepen until reaching the periosteum.
Once a pressure ulcer has occurred, it is a heavy burden for the patient, since this type of injury requires constant treatment and heals very slowly. For this reason, it is especially important to avoid lying supine in sick and bedridden patients. A pressure ulcer can be prevented by taking different measures, for example, by changing the position of the body, keeping the skin clean and well taken care of and placing preventive measures like anti-bedsores to relieve those parts that can quickly ulcerate.
Pressure Ulcer Definition
A pressure ulcer or decubitus ulcer is an injury to the skin and underlying tissue due to the pressure which is subjected to for a long time. Alteration of the skin and tissue can be observed with the naked eye.
The term decubitus derives from the Latin decumbere and means to lie down. This refers to the patient’s sores. Originally pressure ulcers were referred to as decubitus gangrene, whose designation derives from the Greek Gangraina (devouring ulcer), which means putrid wound produced by lying state. Later, only the abbreviation was left to define them.
What Causes Pressure Ulcer?
The cause of pressure ulcers are constant pressure exerted against the skin that can lead to deterioration of small blood vessels. Under normal conditions, person often changes his position several times during sleep to prevent parts of the skin from being compressed between the bones and the base on which they rest.In the case of patients in bed, this is not possible since they can not move or turn by themselves and remain in the same position for a long time. This permanent pressure on the skin compresses the small blood vessels so that the corresponding area is deprived of the oxygen of the blood. The consequence is the death of the tissue and appearance of an ulcer by decubitus.
In principle, a pressure ulcer can appear anywhere on the body that is not protected by muscles or fatty tissue due to a high pressure of support. In supine position, the most exposed body parts are mainly the sacrum, heels and elbows. Minor trochanter of the femur and ankles are exposed in lateral decubitus.
People who have been bedridden for a long time and who have a rather limited movement capacity are the ones who are at increased risk for an pressure ulcer. This group mainly includes the elderly, paralytic or seriously ill (after an accident, for example), patients with stroke or diseases such as multiple sclerosis. Another important risk factor for the appearance of decubitus is urinary incontinence which favors ulceration by modifying the protective acid-fatty layer of the skin due to the patient’s long stay on the moisture, which in turn causes the colonization of germs on the affected area. In addition, those affected by metabolic diseases, such as diabetes mellitus and circulatory disorders and coronary insufficiency (heart failure) are more likely to form pressure ulcers.
What are the symptoms of pressure ulcer?
Pressure ulcer depends on its shape and severity of the affected area. If pressure ulcer is infected, it can give off a strong and unpleasant stench. Constant pains can result for the patient so overwhelming that ends up causing him fear and depression, as well as a strong apathy.
In addition, if there is a nerve injury produced by another disease (polyneuropathy), patient does not feel the symptoms and discomfort that normally accompany with pressure ulcer.
How is pressure ulcer diagnosed?
The clinical picture of the patient allows the diagnosis of a pressure ulcer. The damage produced by pressure ulcer on the skin and the tissue can be observed with the naked eye (visual diagnosis). Depending on the external appearance of the ulcers, as well as the shape and state of the damage, they can be classified into different levels of severity. The most common is a graduation in four phases according to the extent of depth that has reached the ulcer in its penetration into the tissue:
- Grade I: the affected tissue is red
- Grade II: The affected skin appears superficially damaged or shows blisters
- Grade III: Ulcer reaches all layers of the tissue until it touches muscles, tendons or fatty tissues.
- Grade IV: Ulcers reach the bone (bone or periosteum is infected). The affected tissue is necrotic and acquires a bluish black tone.
Once skin examination has given the first diagnosis for pressur ulcer, tissue swabs provide important indications for the correct treatment of the wound. If bone is infected, it will be necessary to perform an X-ray or other imaging methods (bone scintigraphy) which will allow a better calibration of the degree of deterioration.
How is pressure ulcer treated?
The first point of treatment is to eliminate the pressure source by regularly changing the patient’s position so that the ulcerated zone is not pressured. To achieve this goal, a regular change of posture is recommended at least every 2 hours. It is also advisable for the patient to move by himself, whenever possible. When propitiating movement, it is important to pay attention so that the ulcer never gets under pressure. For this, there are special supports (sheets, mattresses and pillows or anti-cushion pads) that favor a distribution of adequate and uniform pressure.
It is important to receive a correct treatment once the ulcer has formed. The treatment consists of a thorough cleaning of the entire lesion with saline serum and sterile gauze. It is important to keep the pressure ulcer clean with wet and sterilized wipes at least twice a day. It is important to use wet bandages so that the dressing material does not adhere to the open wound. Dry bandages that stick together are difficult to remove and produce severe pain resulting in a rapid reopening of the wound. In addition, a humid climate favors healing of the wound. When changing the dressing, it is necessary to carefully wash the ulcer with suitable solutions (0.9% sodium chloride solution) and then cover it with hydrogels and hydrocolloids moistened so that bacteria can not penetrate the wound from the outside.
It is not advisable to use disinfectants containing perfumes or oils to clean an ulcer since they can trigger allergic reactions. It is also not appropriate to apply ointments on an ulcer because they cover the pores and prevent their sweating or powders that form crusts on the surface of the wound. There is a material specially designed to treat open decubitus ulcers. It is important that relatives who take care of a patient with ulcers in their home always consult the doctor or health personnel.
It should be added that in the treatment of pressure ulcers, it is necessary to surgically remove the remains of dead tissue. Deep or large wounds can be covered with grafts of the skin itself. If a pressure ulcer causes a widespread bacterial infection in the body, it will be treated with antibiotics.
Pressure ulcer process
Once a pressure ulcer has developed, it usually takes a long process of evolution. It often takes months for the ulcer to heal completely. The healing process goes through several phases. For this reason, it is very important to regularly inspect the wound and to be able to make any necessary adjustments according to the evolution of the cure and the treatment of the ulcer. To ensure that treatment is successful, it is recommended that both patient and family members work closely with health care providers and physicians.
It should not be forgotten that even after curing, there is still a high risk that the decubitus ulcer (pressure ulcer) will recur in the same affected area.
Pressure ulcer complications
A pressure ulcer can evolve resulting in various complications. Mainly because of its tendency to expand deeply into the tissue. If proper treatment is not performed in time, the affected tissue becomes necrotic. In that case, it will have to be removed surgically.
As disease pathogens can enter into an open sore, there is a danger of bacterial infection. If the infected ulcer reaches the bone, an acute inflammation of the bone marrow (osteomyelitis) may form. In addition, the pathogen can spread throughout the body through the bloodstream, which can lead to a bone abscess, a lung infection or even a serious infection in the blood (sepsis) with subsequent organ deterioration, which can be a very serious complication.
If pressure ulcer extends extensively through the skin, the patient also loses protein and nutrients constantly. This can lead to malnutrition, which in turn would cause a delay or paralysis of wound healing.