Pressure ulcers (also known as pressure injuries, bed sores, pressure sores and decubitus ulcers) are localised injury to the skin, underlying tissue or both, usually over a bony prominence, as a result of pressure or pressure in combination with shear. It is found on the sacrum, heels, over the greater trochanters, occiput, shoulders, etc.
Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis
Risk Factors
- Age,
- Immobility (especially post-operative),
- low or high body weight,
- Current smoking history,
- Dry skin
- Malnutrition,
- Dehydration,
- Incontinence,
- Neurological damage (either neuropathy or reduced consciousness level),
- Use of sedative drugs, and Vascular impairment.
Risk Assessment tools
They include:
- Braden Risk Assessment tool,
- Waterlow score,
- Norton risk assessment scale,
- PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool).
Prevention
The key to preventing pressure ulcers is to accurately identify at-risk individuals quickly, so that preventive measures may be implemented.
• Turning and handling—Two-hourly turns have been suggested although rarely achieved. Frequency should be judged individually. Modern mattresses reduce frequency but do not eradicate the need for turns. Avoid friction and sheer by using correct manual handling devices. Consider limiting sitting out to 2hours.
• Encourage early mobilization; optimize pain control, and minimize sedative drugs.
•During skin care, avoid vigorous massage over reddened, bony prominences because evidence suggest that this leads to deep tissue trauma. Skin breakdown caused by friction may be mitigated by the use of lubricants, protective films (e.g., transparent and skin sealants), protective dressings (e.g., hydrocolloids), and protective padding.
•Pressure-relieving devices—consider for beds, chairs, and localized body parts (e.g. heels). Wide variety available(ripple mattress, water bed)—balance pressure relief with cost and limitation to independent mobility.
Promote a healing environment:
• Nutrition—protein, vitamins and calorie supplements. AHRQ pressure ulcer prevention guideline suggests that a serum albumin of less than 3.5 gm/dl predisposes a patient for increased risk of pressure ulcers.
• Manage incontinence (one of the few times that a geriatrician might recommend a catheter)
• Good glycaemic control in people with diabetes
• Correct anaemia (normochromic/normocytic anaemia common)
References
•Oxford handbook of geriatric medicine.
•Moore ZE, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2019 Jan 31;1(1):CD006471. doi: 10.1002/14651858.CD006471.pub4. PMID: 30702158; PMCID: PMC6354222.
•Graves N, Birrell F, Whitby M. Effect of Pressure Ulcers on Length of Hospital Stay. Infection Control & Hospital Epidemiology. 2005;26(3):293-297. doi:10.1086/502542