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Pressure Ulcers

The elderly population is increasing in our country and all over the world; and pressure ulcers, one of the geriatric syndromes commonly seen in this age group, are now more commonly encountered. Ischemic tissue loss observed mostly over bony prominences of the body, which develops in consequence of prolonged exposure of tissues to pressure, is defined as pressure ulcer.

Decubitus ulcer is derived from the Latin word for “decumbere”; and ‘bedsore’ and ‘pressure ulcer’ are the other words used to define this pathology. Pressure ulcers are chronic wounds that we commonly encounter with advanced age, cognitive disorders, physical disabilities and multiple co morbidities. They lead to physical dependence and increase caregiver’s workload and health care costs. It is more commonly seen in elderly patients due to physiological changes induced by aging, association of chronic diseases, higher frequency of hospitalization, and longer periods of hospital stay. Despite the advancements in the field of medicine, and the fact that such ulcers are avoidable, they continue to be an important health problem in our country and all over the world. In acute care hospitals, the prevalence rate of pressure ulcers is 3-15%, although it has been found to be different in many studies. This ratio is 50% in an intensive care unit with standard beds.

Pressure ulcers can be prevented before they occur. Its prevention is first based on a good maintenance. An emergent ulcer does not cause only the patient to feel pain and get harm but also creates a material and spiritual problem that is of a concern to his/her family, caregiver, nurse, doctor and even the whole society. Prevention of pressure ulcer is the most humanistic and inexpensive approach required.

What are the Risk Factors ?

Pressure ulcers can develop in every area where there exist bony prominences. They are most commonly seen in the sacrum (tailbone), coccyx and heels of patients who constantly lie back; in the hip and ankle of patients who constantly lie on one side; and in the hips of patients who constantly sit. An external pressure is required to exist on the skin for the development of a pressure ulcer; however, this alone does not cause a pressure ulcer, and there must be certain patient-specific facilitative factors, as well. Pressure ulcers occur in patients who need long-term care, with the contribution of two types of facilitative risk factors as intrinsic (patient-related) and extrinsic (non-patient-related) factors. External factors are divided into four groups as pressure, shearing effect, friction, and moisture.

External Risk Factors

Pressure: Pressure is the most important factor that plays a role in the formation of pressure ulcer. When a pressure greater than the arterial pressure is applied to the skin, the distribution of oxygen and nutrients to the tissues are impeded, and the resultant tissue hypoxia leads to the accumulation of metabolites and free radicals. If this pressure is not eliminated, necrosis and ulceration develop. Pressure is greater on the weight-bearing bony prominences, which contact the outer surface. In ulcers caused by pressure, redness or a small ulceration is observed on the skin; but in fact, it leads to a cone-shaped distribution of tissue damage in deeper tissues. In ulcers caused by pressure, the muscles are the most sensitive ones in terms tissue sensitivity, which are followed by subcutaneous adipose tissue and dermis.

Shearing effect: In elderly people lying in a laterally inclined position, pressure ulcers develop in deep tissues including the muscle and subcutaneous adipose tissues in particular. When an elderly patient lies in a laterally inclined position, the body slides downwards, or when he/is pulled upwards on the bed, the contact of the epidermis and dermis with the external surface remains stationary while the deeper tissues are pulled downwards. This leads to excessively stretched blood vessels and a mechanical effect on the epidermis. The condition develops when the tissues are pulled in parallel with each other but, in the opposite direction.

Friction: Friction is a condition that involves the loss of the top layer of the skin due to its dragging across the external surface. It is not accompanied by ischemia. It emerges due to mistakes made when changing the position of the patient. Friction mostly leads to stage 2 pressure ulcers, and it has limited contribution to the development of stage 3-4 pressure ulcers.

Moisture: In the skin moisturized with feces, urine, and sweating, the resistance of the epidermis decreases and leads to maceration; and with also the effect of pressure, ulcerations occurs. Urine and feces incontinence, excessive sweating, and wound drainage causes a humid environment in the patient. The contribution of moisture to the formation of pressure ulcers is less compared to the other factors.

Internal Risk Factors

The list can include age, immobility, urinary and fecal incontinence, anemia, dry skin, malnutrition, neurological diseases, hypotension-ischemia, spasticity, infection, decrease in muscle mass and spinal cord injuries.

With aging, some changes occur in the skin. The dermal-epidermal junction gets thinner, and the dermo-epidermal junction can easily be separated. Abrasion and bullae may occur during the removal of the bandage, as a result of easy separation of the dermis and epidermis. The wound healing in dermis delays due to the impairment of the vascular structure in the dermis and the decrease in the collagen synthesis. The layer between the bone and skin reduced in consequence of the decrease in the subcutaneous adipose tissue paves the way for ulcer formation.

Besides the physiological changes in the skin that occur with aging, also the steroid treatment intended for diseases commonly seen in this age group leads to a decreased collagen synthesis and thinner skin; and consequently, paves the way for ulcer formation.

Cerebrovascular events, spinal cord injury, multiple sclerosis, prolonged surgery, trauma, and immobility caused by advanced musculoskeletal system diseases are the most important intrinsic factors in the development of pressure ulcers.

Fecal and urinary incontinence is facilitative factors for pressure ulcers. Urinary incontinence leads to a five-fold increased pressure ulcer. Urinary and fecal incontinence leads to maceration in the skin, and paves the way for infection development.

Patients, who have an impaired nutrition and a body mass index (BMI) below 25 kg/m2, are at the risk in terms of pressure ulcer development. Hypotension, dehydration, vasoconstriction secondary to shock, heart failure, and medications pave the way for ulcer formation by contributing to tissue ischemia. Since patients cannot express the discomfort they feel as a result of staying in the same position for a long time in diseases affecting the mental states of patients, especially in cases that involve dementia, development of pressure ulcers becomes easier. Patients who had previously developed a pressure ulcer is at a higher risk of developing a new pressure ulcer, compared to an elderly patient.

How to Stage a Pressure Ulcer ?

The American National Pressure Ulcer Advisory Panel (NPUAP) is the most commonly used pressure ulcer staging system.

Stage 1
Intact skin with non-blanchable 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. Further description: The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).

Stage 2
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. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
*Bruising indicates suspected deep tissue injury

Stage 3
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage 4
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Further description: The depth of a stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

What are the Pressure Ulcer Complications ?

Pressure sores have both medical and psychosocial aspects. Stage 3-4 pressure ulcers lead to life threatening medical complications. The psychosocial aspect is often overcome, however, the pain that the patient feels, his/her loss of control in his/her life, and the requirement of daily wound care impair his/her daily life activities, and finally result in depression and social isolation. Infections constitute another complication. Each pressure ulcer serves as a reservoir for bacteria, which have gained antibiotic resistance in hospital; and this may cause slow wound healing and may pose a risk of bacteraemia and sepsis. It may lead to the development of dermal sinus tract, heterotrophic calcification, systemic amyloidosis induced by chronic inflammation, and squamous cell carcinoma

How do We Prevent Pressure Ulcers ?

The measures required to be taken for the prevention of pressure ulcers are easier and more economical than their treatment. Training is the first stage in the prevention of pressure ulcers. The patient and his/her family as well as hospital personnel should be trained on the causes and consequences of such ulcers.

The areas of the body, where pressure ulcers are common, are the heels, sacrum, ischial tuberosity and trochanter should be checked on a daily basis. The reduction of pressure is the most important factor in the prevention of pressure ulcers. Position can be changed for this purpose. If the patient is bed or wheelchair dependent, pressure-reducing mattresses and cushions should be used. The position should be changed at least after every two hours if the patient is bed dependent; and on an hourly basis if the patient is wheelchair dependent. When positioned, the patient should not be placed vertically; instead, he/she should be placed on his/her side at a 30 degree angle. In vertical lying position, the trochanter remains under pressure, and this leads to an increased risk of pressure ulcer development. Position changes ensure the microcirculation to continue, by reducing the pressure in the areas, which are at the risk of pressure ulcer development. Appropriate techniques should be used during position changes, in order to prevent friction and shearing. Pillows or foam wedges should be placed between the ankles and knees to prevent friction between them. Pillows should be placed under the lower legs up to the ankles, in such a way to elevate the heels to prevent them from contacting the surface. In dynamic or static systems intended for reducing the pressure, mattresses can be used to prevent pressure ulcer. Nutrition should be considered to be a part of the patient care, and supportive care should be provided to patients, whose calorie and protein intake is inadequate. Nutritional support enables the treatment of early-stage pressure ulcers and prevents their transformation into chronic ulcers. For keeping the moisture under control, the factors that cause moisture such as sweating, wound drainage, wetness after bath, and fecal or urinary incontinence should be investigated, and the skin should always be kept clean and dry.

How can Pressure Ulcers be Treated ?

Conservative Treatment: If a pressure ulcer occurs, the necessary measures should be taken before it becomes complicated. At stage 1 and 2, recovery is ensured if the pressure is eliminated and a good skin care is provided. If the pressure continues, the wound gets deeper and complicated.
Many topical agents are used in wound care. Lactated Ringer’s solution and physiological saline solution are the ideal solutions that can be used in wound cleaning process. Betadine solution has a nature that leads to minimal damage to cells, and can be used for affected wounds.

Antibiotics used topically are still controversial, but bacteria resistant to these may develop in a short time. They are not economical. Antibiotics given systemically cannot reach the wound areas, due the barriers that form in the wounds. Systemic antibiotics should be administered against secondary infections.
Although the flora often changes in such wounds, a wound culture is required in terms of nosocomial infection.
In recent years, many synthetic and semi-synthetic materials intended for wound care have been developed. Most of them are not economic, and are used improperly. These materials should be used only as a temporary skin cover in cases that may delay the surgery, if the wound is clean and if there is no necrosis. Some of them prevent the loss of fluid, electrolyte and protein from the body.

Surgical Treatment: At stages 3, 4, and 5 pressure ulcers, surgical procedure is carried out. If the patient’s blood values are low in preoperative period, they should be brought to normal values suitable for surgery.
Necrotic tissue should be removed as soon as possible, for achieving a successful result from the pressure ulcer treatment. For this, enzymatic debridement procedures, surgical debridement procedures, as well as defect repair procedures should be preferred. The treatment is intended for providing the wound area with healthy pressure-resistant tissues that have a good blood circulation. Since muscle-skin and fascia-skin flaps used in repair have a good blood circulation, they are superior to other repair procedures in the fight against infection of wound areas.