Pressure ulcers (PUs), also known as bedsores, are localized injuries of the skin. PUs manifest in four stages. The late stage is characterized by full thickness tissue loss and exposed bone, tendon or muscle tissue.
PUs occur most frequently over bony prominences such as the sacrum, coccyx (just above the natal cleft), heels and ear. Compression of the soft tissues over the bony prominence causes decreased blood flow to the skin, muscle and fascia in the compressed region between the skin surface and bone.
This decreased blood flow is largely the result of the compression of small vessels in the compressed tissue, and this, in turn, blocks the local supply of oxygen and nutrients at the capillary interface. If pressure is prolonged, metabolic wastes accumulate and enlarge the blood vessels.
This enlargement contributes to local swelling, further compressing the small vessels in the affected region, leading to more swelling and decreased blood flow. Ultimately, this cycle results in local tissue death, which culminates in the formation of a pressure ulcer.
Patients admitted to intensive care units are at a higher risk of developing PUs. A review of ICU-related literature from 2000 to 2005 indicated PU prevalence in the ICU of four to 49 percent.
The 2009 International Pressure Ulcer Prevalence Survey indicated that facility-acquired PU prevalence rates were highest (12.1 percent) in the medical ICU and, now that COVID-19 is here, this will even be higher.
You may be at risk of developing pressure ulcers for a number of reasons, including advanced age and the following:
Problems with movement: If your ability to move is limited, you don’t get enough oxygen to the parts under pressure and skin integrity can deteriorate in hours.
Poor blood circulation: Vascular disease or smoking reduces your circulation.
Moist skin. You may be at increased risk if your skin is too damp due to incontinence, sweat or a weeping wound
Lack of sensitivity to pain or discomfort: Conditions such as diabetes, stroke, nerve/ muscle disorders etc., reduce the normal sensations that usually prompt or enable you to move if you feel anything. Some treatments reduce your sensitivity to pain or discomfort, so you are not aware of the need to move.
Previous tissue damage: Scar tissue will have lost some of its previous strength and is more prone to breakdown.
Inadequate diet or fluid intake: Lack of fluids may dehydrate your tissues.
Frequent assessment prevents minor damage from becoming major ulcers. To assess your risk of developing pressure ulcers, a member of your healthcare team will examine/assess you and ask you some questions. This will help to identify if you require specialized equipment or other forms of care, and will assist in providing for your individual needs.
The early signs of a pressure ulcer are redness (non-blanching when finger pressure applied is not good. Press your finger over the reddened area for 15 seconds then lift. If the area turns white or pale, it is not a stage 1 pressure ulcer. If it stays red, it is a stage 1 pressure ulcer); discoloration (dark red, purple, black); heat or cold (warmer or cooler area over a bony prominence); discomfort or pain, soreness; a spongy feeling; a hardened area; blistering; and skin damage (broken skin, ulcer).
THE PREVENTION CARE BUNDLE
The pressure ulcer bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure-ulcer risk assessment, and care planning and implementation to address areas of risk.
These risk areas include the surface you or the patient is sleeping on. Select the correct mattress according to guidelines. Use a pressure-reducing cushion when sitting up in a chair. Use foam or padded dressings over bony areas (e.g. Mepilex). Do not use multiple layers under the patient Reassess pressure ulcer risk and equipment requirements daily.
Keep moving. Reposition the patient every four hours when in bed. Shift the patient’s weight at least every two hours if in a chair. Document position changes on a repositioning chart. Inspect the skin and document at every position change, or once every 24 hours if the patient moves unaided. Encourage mobility. Provide written advice on preventing pressure damage.
To avoid incontinence, offer toilet assistance regularly according to individual need.
A complete nutritional risk assessment is necessary. Follow nutritional recommendations according to risk score. Ensure optimal nutritional intake. Keep the patient well hydrated.
Initiate timely discharge planning to prevent delays. Review pressure-ulcer risk and equipment requirements for the home. Document the condition of skin/wounds in nursing notes and upon discharge. Provide the patient and caregivers with information regarding ongoing care.
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