Management of Pressure Ulcers
Staging and Treatment of Skin Breakdown From Continuous Pressure
May 16, 2008
Pressure ulcers, also called pressure sores, bedsores, and decubitus ulcers, are a frequent problem for immobile patients, especially the elderly. They are a common issue in hospitals and nursing homes. It is no wonder that many steps are taken to assess, treat, and prevent these wounds.
Pathogenesis and Staging
When lying or sitting down, pressure is continuously applied over the skin of support areas, particularly bony prominences. This cuts off the flow of blood to the tissues in this area. Normally, this does not last very long because of position changes, such as turning or moving to a more upright position. This may not be the case, however, if a person is immobile, such as from major amputation of the lower extremities, significant fractures of the lower body, severe obesity, or even major depression. After being in a bed or chair for an extensive period of time, the soft tissues are deprived of blood long enough to actually die. This can result in wounds and ulcers in places like the lower back and buttocks.
The severity of this change in tissue depends on many factors, including the duration of pressure, friction and shear forces, and the person's ability to heal, which in turn depends on factors like nutrition and the presence of diabetes mellitus. The National Pressure Ulcer Advisory Panel (NPUAP) developed the following staging system for pressure ulcers:
- Stage I - The skin is intact with changes in color, temperature, or texture.
- Stage II - The epidermis, and sometimes a portion of the dermis as well, is stripped away, leaving a shallow wound.
- Stage III - There is loss of the full thickness of the skin with underlying subcutaneous tissue exposed.
- Stage IV - The wound is deep enough to expose muscle, bone, and tendons.
- Unstageable - The depth of the wound cannot be determined, either because there is intact skin overlying deeper tissue changes or because the base of an ulcer is covered in debris.
Treatment and Prevention
Treatment of the wound depends very much on the stage of the wound. A variety of treatment options are available, including the following:
- Cushions and support surfaces to minimize pressure on the ulcer
- Moisturizers and other topical agents to prevent breakdown of intact skin
- Wound cleansers for open wounds
- Enzymatic agents to remove dead tissue (debridement)
- Dressings to cover and protect the wound
- Surgery for sharp debridement or rapid wound closure
- Treatments for wound complications, such as antibiotics for wound infection and analgesics for pain
Prevention still remains an important measure for pressure ulcers. To minimize continuous pressure over support areas and bony prominences, activity should be encouraged whenever possible, and relatively immobile patients in hospitals and nursing homes should be turned every so often. Concurrent hygiene is also helpful. Only by taking these measures can pressure ulcers and their complications be reduced.
