What is a Pressure Ulcer and Who is at Risk?
How many of you have had a pressure sore or had a patient with a pressure sore? They are terrible, aren’t they? Well the good news is, they are preventable. Over the years, the nomenclature has changed from Decubitus to bed sores to pressure ulcers. As of April 2016, the National Pressure Ulcer Advisory Panel (NPUAP) has changed the nomenclature once again to pressure injury. However, this terminology has not yet been accepted by many insurances, including Medicare. So, what exactly is a pressure ulcer? NPAUP’s definition states, “A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.” The patients that are at a high risk of these type of injuries are people with spinal cord injuries, stroke, ICU patients, comatose patients, elderly, contractures, malnourished, dehydrated, and intra/post-operative people. The elderly, malnourished, and dehydrated people all have decreased skin turgor, therefore, making their skin thin, fragile, and at an increased likelihood of tearing. Spinal cord injuries are at a high risk due to sensation loss and inability to pressure relieve. ICU patients are at a high risk do to the microclimate (heat and moisture) as well as incontinence and bed positioning. There is an assessment tool called the Braden Scale that is used to determine a patient’s risk of developing a pressure ulcer. More on this assessment tool can be found at http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=960&Source=http%3A%2F%2Fwww%2Erehabmeasures%2Eorg%2FLists%2FRehabMeasures%2FAdmin%2Easpx.
So, how are these injuries staged? They are staged as stage 1, stage 2, stage 3, stage 4, unstageable, deep tissue pressure injury, medical device related pressure injury, and mucosal membrane pressure injury. The chart below explains stage 1 – deep tissue injury (DTI). A medical device related pressure injury is an ulceration that has occurred due to a medical device designed or applied to produce a therapeutic or diagnostic effect (i.e. Foley catheter, AFO, casts/splints, etc. These types of injuries can be staged using the staging system mentioned above. However, mucosal membrane injuries cannot be staged due to the anatomy of the tissue affected. These injuries occur on the mucous membranes due to medical devices used in the are (i.e. rectal tube, nostril insertion of nasal cannulae, endotracheal tube).
Over 95% of all pressure injuries occur at the sacrum/coccyx, greater trochanter, ischial tuberosity, heel and lateral malleolus. Preventing pressure injuries has a lot to do with positioning and patient/family/caregiver education. A study by Peterson et al. found that interface pressure exceeded capillary occlusion range when the head of bed was elevated above 30 degrees. What does that mean? If the head of the bed is elevated >30 degrees, then it will increase the shear force on your backside, putting you at an increased risk of developing a pressure ulcer. This leads me to talk about positioning. If a patient is confined to a wheelchair, they need to do a wheelchair push-up/pressure relief every 15 minutes. If they are unable to complete a wheelchair push-up, they need to adjust themselves to a 35 degree or 65 degree angle to offload the sacrum and ischial tuberosity’s. The individual could also lean-to one side then the other in their chair. In regards to an individual bed bound, their position should be changed every 2 hours. Each patient should be inspected daily for pressure injuries. It is important to speak with the patient/family/caregiver to instruct/show them how to pressure relief and how they can assist. Proper positioning in bed to reduce likelihood of pressure ulcers is to limit a large pillow behind the head (prevents contractures), head of bed elevated no more than 30 degrees. In sidelying, place the individual 150 degrees from supine (not on their greater trochanter) and place a pillow between their knees. Prone is the best position, but not many people want to lay in this position!
Just remember, pressure injuries ARE preventable! EDUCATE, EDUCATE, EDUCATE!!!
McCallon, Stan (2017). Pressure Injuries. Lecture. LSUHSC Shrevepot.
McCulloch, J. M., & Kloth, L. (2010). Wound healing: evidence-based management (4th ed.). Philadelphia: F.A. Davis.