PRESSURE SORES

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Pressure sores, also known as pressure ulcers or bedsores, are areas of damaged skin and tissue caused by prolonged pressure on the skin. These sores typically develop on bony prominences, such as the hips, heels, elbows, and back. They occur when you remain in one position for too long, causing the weight of your body to cut off blood supply against the surface of a bed or chair. This often happens during extended periods of bed rest or while using a wheelchair.

Your doctor might discuss the “stage” of your pressure sores, which refers to how deep they are and can impact the treatment approach. When pressure sores are detected early, there’s a good chance they will heal within a few days with minimal discomfort. However, if left untreated, they can worsen over time.

Causes

Pressure sores, also known as pressure ulcers, develop when your skin experiences prolonged pressure against a surface such as a mattress or cushion. Also, this pressure hinders blood flow to the affected area, leading to the death of skin cells and increased sensitivity. Pressure sores can appear within a few hours or days.

Several factors contribute to the formation of pressure sores:

1. Pressure: Even if you don’t feel like you’re applying much weight to a particular body part, continuous pressure over time accumulates. This pressure compresses the skin, obstructing blood flow and depriving the skin of oxygen and nutrients, weakening it and causing cell death.
2. Rubbing: Friction from bedding or clothing can harm delicate skin, particularly when it’s moist from perspiration.
3. Skin Stretching: Movement between two surfaces can cause the skin to stretch or pull, exacerbating the risk of pressure sores. For instance, sliding down a raised bed can irritate the skin on the tailbone.

Pressure sores commonly develop in bony areas of the body where there’s little fat or muscle padding. The specific areas where they occur depend on your position:

• When lying in bed, pressure sores are often found on the head (where it rests against the pillow), shoulder blades, hips, tailbone, buttocks, back of the knees, ankles, and heels.
• When using a wheelchair for extended periods, pressure sores may develop on the shoulder blades, spine, or on the arms or legs where they come into contact with the chair.

Additionally, pressure sores can arise from devices that apply prolonged pressure to the skin. For instance, wearing an oxygen mask can lead to pressure sores on the nose, ears, or the back of the head. Similarly, poorly fitting oral devices like dentures can cause sores inside the mouth.

Prevalence

These sores are prevalent among individuals who are bedridden, wheelchair-bound or have limited mobility. They are common in hospitals, nursing homes, and long-term care facilities.

Stages and Symptoms

Pressure sores, also known as bedsores, progress through four stages, each indicating the severity of tissue damage:

1. Stage I:

• In this initial stage, the pressure sore affects only the upper layer of the skin.
• Symptoms include pain, burning, or itching, along with changes in skin texture compared to surrounding areas.
• A red area may be visible on the skin, though it may be challenging to discern in individuals with darker skin tones.
• The affected area remains discolored even after pressure is relieved, indicating compromised blood flow.

2. Stage II:

• This stage occurs when the sore penetrates deeper beneath the skin’s surface.
• Symptoms include broken skin, an open wound, or a blister filled with pus.
• Surrounding skin may appear discolored, and the area may be swollen, warm, and tender.

3. Stage III:

• Pressure sores progress to this stage when they extend through the second layer of skin into the underlying fat tissue.
• Symptoms include a visible “crater-like” appearance of the sore and signs of infection such as redness, pus, odor, heat, and drainage.
• The tissue surrounding the sore may appear black if it has become necrotic (dead tissue).

4. Stage IV:

• This is the most severe stage, with pressure sores extending deep into the muscles, ligaments, or even bones.
• Symptoms include a large, deep sore with blackened skin and signs of infection.
• Tendons, muscles, and bones may be visible through the wound.

Additionally, there are two other stages of pressure sores:

• Unstageable: Occurs when the bottom of the sore is covered by a layer of dead skin, making it impossible to determine its depth until the dead tissue is removed.
• Suspected deep tissue injury: The skin’s surface resembles a Stage I or II sore, but underlying tissues are at Stage III or IV, indicating significant damage.

It’s essential to monitor pressure sores closely and seek medical attention for proper staging and treatment.

Risk Factors

Several factors can increase the risk of developing pressure sores, also known as bedsores. These include:

1. Immobility: Difficulty moving can lead to spending extended periods in one position, subjecting certain body parts to pressure.
2. Incontinence: Lack of control over bladder or bowel movements can result in moisture from urine and feces, which may irritate the skin, especially if prompt cleaning is not possible.
3. Poor nutrition and hydration: A healthy diet providing sufficient nutrients and hydration is essential for maintaining skin health and overall bodily function. Without proper nutrition and hydration, the skin becomes weak and prone to damage.
4. Loss of physical sensation: Conditions such as spinal cord injuries can diminish the ability to feel pain or discomfort, making it difficult to recognize when pressure is building up on certain body parts, increasing the risk of pressure sores.
5. Blood flow problems: Conditions like diabetes and vascular disease can impair blood circulation, making it easier for certain positions to cut off blood supply to tissues, leading to pressure sores.
6. Thin or weakened skin: Wearing casts or prosthetic devices can weaken the skin, making it more susceptible to pressure and irritation.

Additionally, certain health conditions elevate the risk of pressure sores due to their impact on mobility, blood flow, and other contributing factors. These conditions include:

• Cancer
• Cerebral palsy
• Coma
• Dementia
• Diabetes
• Heart failure
• Kidney failure
• Malnutrition
• Paralysis
• Spinal cord injury or spina bifida
• Vascular problems

Individuals with these conditions often face challenges in movement and circulation, increasing their susceptibility to pressure sore development.

Diagnosis

Diagnosing pressure sores involves a thorough examination by a doctor, along with consideration of symptoms and medical history:

1. Physical Examination: The doctor will visually inspect the skin and ask questions regarding the sore, including when it appeared, whether it causes pain, and how frequently positions are changed. Past occurrences of pressure sores are also relevant.
2. Staging: Based on the examination and symptoms, the doctor determines the stage of the pressure sore, which helps guide treatment. They may document the sore’s progress with photographs.
3. Additional Tests: If infection is suspected, further tests may be conducted:
   • Blood tests: To check for signs of infection.
   • Biopsies: Taking a tissue sample from the sore for testing.
   • Imaging: X-rays or MRIs to assess the extent of tissue damage beneath the skin.

Treatments

Treatment for pressure sores varies depending on the stage of the sore:

1. Stage I:

• The primary goal is to relieve pressure on the affected area. Change positions frequently and utilize foam pads, pillows, or special mattresses.
• Maintain skin hygiene by washing the sore with mild soap and water and drying it gently.
• Follow a diet rich in protein, vitamins A and C, iron, and zinc, and stay hydrated.

2. Stage II:

• Clean the wound with a saline solution and cover it with an appropriate bandage recommended by your doctor.
• Monitor for signs of infection, such as pus, fever, or increased redness, and inform your doctor promptly.

3. Stage III:

• Seek medical attention for stage III sores. Your doctor may perform debridement to remove dead tissue either through a surgical means or with special ointments.
• Antibiotics may be prescribed to treat or prevent infection.
• Specialized beds or mattresses may be recommended for better wound management.

Stage IV:

• Immediate medical attention is crucial for stage IV pressure sores, which may require surgery.
• Surgical interventions may include skin grafts, where tissue from another part of the body is used to cover the wound and promote healing.

Medications and pain management:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help alleviate pain and inflammation. Take them before changing positions or cleaning the wound.
• Topical pain relievers in the form of creams or ointments may be prescribed by your doctor.
• Antibiotics may be necessary if the sore becomes infected.

Surgical treatments:

• Skin graft surgery may be recommended for large, persistent pressure sores. This procedure involves transplanting muscle or skin from another area of the body to cover the wound and facilitate healing.

Home Care Tips

If caring for someone with pressure sores at home, consider the following tips:

1. Ensure proper nutrition with a balanced diet rich in protein and vitamins.
2. Keep the skin clean and dry, avoiding prolonged exposure to moisture.
3. Encourage regular movement and repositioning to relieve pressure on vulnerable areas.
4. Use cushions or padding to protect bony prominences.
5. Seek medical advice if there are signs of infection or worsening of the sore.

Prevention

Preventing pressure sores is essential, and there are several simple steps you can take:

1. Regularly change positions: Reposition yourself every 15 minutes if you’re in a wheelchair, or every hour if you’re in bed. Don’t hesitate to ask for assistance if needed.
2. Use specialized equipment: Consider getting a wheelchair that can tilt back, allowing you to shift your weight more easily. Use cushions and specialized mattresses to distribute your weight evenly and support your body in comfortable positions. Avoid doughnut cushions, as they can increase pressure on surrounding areas.
3. Keep the head of your bed low: Avoid raising the head of your bed or tilting your pillows to more than a 30° angle to prevent sliding down the bed, which can strain the skin around the tailbone.
4. Lift yourself if possible: If you have enough upper body strength, perform wheelchair push-ups by pressing your forearms against the chair’s arms to lift your body.
5. Maintain cleanliness and dryness: Use daily cleansing towels to wipe away sweat, dirt, and other buildup, and pat dry afterward. Apply moisture barrier ointment if you have incontinence to protect your skin from urine and feces.
6. Avoid skin irritation: Check for buttons, zippers, or bumps in fabric that could cause rubbing and wash your blankets and clothes frequently.
7. Eat a healthy diet and stay hydrated: Proper nutrition and hydration are essential for maintaining strong, healthy skin.
8. Monitor your skin: Regularly check for signs of pressure sores and seek treatment promptly if any are detected.

Complications of untreated pressure sores

Complications of untreated pressure sores can be severe:

1. Skin Infections: Open wounds are susceptible to bacterial infections like cellulitis or septicemia, characterized by warmth, swelling, and inflammation.
2. Sepsis: Untreated infections can escalate to sepsis, where the body attacks its own tissues instead of fighting the bacteria, potentially leading to life-threatening complications.
3. Amputation: Severe sepsis may necessitate limb amputation.
4. Bacteremia: Bacteria entering the bloodstream can cause serious conditions like bacterial meningitis or endocarditis, affecting the brain and heart.
5. Bone and Joint Infections: Pressure sores can facilitate infections in nearby bones or joints, impairing mobility and causing tissue damage.
6. Cancer: Prolonged non-healing wounds may rarely develop into squamous cell carcinoma, a type of skin cancer.

Signs of an infected pressure sore include:

• Fluid leakage from the sore
• Fever
• Foul odor
• Warmth around the wound
• Changes in skin color
• Swelling
• Pain

Early detection and proper treatment are crucial to prevent complications associated with pressure sores. Regular monitoring and prompt medical attention for any signs of infection are essential for managing pressure sore complications effectively.

When to See a Doctor

It’s essential to consult a healthcare professional if you notice any signs or symptoms of these sores, especially if you are at increased risk due to immobility or chronic health conditions. Early intervention can prevent complications and promote faster healing.

Outlook/Prognosis

The outlook for these sores depends on various factors, including the severity of the sore, underlying health conditions, and the effectiveness of treatment. With prompt medical care, proper wound management, and preventive measures, many pressure sores can heal successfully. However, severe or untreated pressure sores can lead to complications such as infection, tissue necrosis, and even death.

Sources

1. National Institute on Aging. “Pressure Sores (Bedsores).”
2. Mayo Clinic. “Pressure Sores (Bedsores).”
3. Clevland clinic
4. National Health Service. “Pressure Sores (Pressure Ulcers).”
5. Centers for Disease Control and Prevention. “Pressure Ulcers in Healthcare Settings.”
6. American Academy of Dermatology Association. “Bedsores: Overview