Pressure Sore Of Tissues Update
Pressure Sore Update by Becky Sisk, PhD, RN
- A pressure sore is an ischemic necrosis and ulceration of tissues overlying a bony prominence that has been subjected to prolonged pressure against an external object (e.g., bed, wheelchair, cast, splint) (Merck Manual Online, 2001). Approximately 10% of hospital patients are afflicted with pressure sores at any time (The National Decubitus Foundation).
[LEEDer Note: see http://www.npuap.org/ This is an excellent resource-CLICK-HERE
The stages of pressure ulcers (decubiti) are:
- Stage I: Skin is intact, erythematous (reddened), and does not blanch. Skin may be firm or boggy, warm or cool to the touch, painful or itchy. Indicators in darker skin are a dark red, blue or purple area; warmth; edema; induration, or hardness.
- Stage II: Superficial ulceration of the skin, appearing as an abrasion, a blister, or a crater. Partial thickness skin loss (dermis or epidermis, or both).
- Stage III: A deep crater; full thickness loss of skin tissue, also involving subcutaneous tissue down to the fascia.
- Stage IV: Full thickness skin loss, with damage to bone, muscles, tendons, or joint capsules. May involve sinus tracts.
- Nonobservable: Covered with a dressing, an orthopedic device, eschar, or slough. Cannot be visualized.
Risk factors for pressure sores are:
- Being bedfast or chairfast, subject to pressure, friction, and shearing
- Advancing age
- Being unable to position oneself
- Having decreased sensory perception
- Poor or decreased nutrition
- Moisture
The Braden Scale for Predicting Pressure Sores is a tool for predicting pressure sores. (see: http://www.bradenscale.com/bradenscale.htm for more details; a PDF file available on this website; click on Health Care Providers)
Assessment of a pressure sore includes its location, stage, size, and surface appearance eg. granulation, necrotic, slough, exudate. Look for sinus tracts and take a color photograph, if possible. The Nursing Outcomes Classification (Johnson, Maas, & Moorhead, 2000, p. 427) provides a more detailed assessment and quantitative tool that includes skin temperature, sensation, elasticity, hydration, pigmentation, perspiration, color, texture, thickness, lesion status, perfusion, hair growth, and intactness. The nursing diagnosis for any altered epidermis or dermis is Impaired Skin Integrity. The PUSH tool, developed by the National Pressure Ulcer Advisory Panel, is used to assess changes in pressure sores with treatment. A description of the tool is on http://www.npuap.org/pushins.htm. A copy of the tool is on http://www.npuap.org/push3-0.htm.
Treatment of pressure sores begins by cleansing with normal saline, using an irrigation device at 4 to 15 pound per square inch (National Guideline Clearinghouse, 1997). Initially, the pressure sore appears to be getting larger with cleansing. Actually, you are removing nonviable tissue.
Debridement of pressure ulcers:
- Surgical debridement
- Mechanical debridement – Removing dead tissue with dressings (NOTE: take care when removing old dressings to avoid tearing healed or healing tissue. This can be accomplished by wetting the old dressing down with normal saline before removing it.)
Dressings that absorb drainage include:
- Hydrogel dressings, used to keep the wound wet and to absorb drainage. Examples include Tegagel and NU-GEL.
- Absorptive dressings, such as Medipore and Iodoflex.
- Alginates, fibers that come from seaweed and absorb drainage, such as AlgiCell and AlgiDERM.
- Collagen dressings, such as BGC Matrix or FIBRACOL, stop bleeding and aids healing.
- Foam dressings that absorb drainage, such as Reston and BIOPATCH.
- Hydrocolloid dressings that absorb drainage. Common brands are Tegasorb and NU-DERM.
- Enzyme preparations, such as Accuzyme or Santyl. Enzymes act on collagen, protein, fibrin, elastin, and nucleoproteins.
- Pressure ulcers are inevitably infected, usually with gram (-), gram (+), and anaerobic bacteria. Treat with oral antibiotics, such as penicillin or cephalosporins, or with antibiotic ointments, such as silver sulfadiazine or triple antibiotic ointment.
*Note that, among the many treatments available for pressure sores, none has been demonstrated to be any more effective than any other (Bradley et al., 1999). Stage 4 pressure sores require surgery, often with debridement to the bones.
Pressure Sore Facts & Hints
- The stages of pressure sores were revised a few years ago to include assessment of people with dark skin color.
- Iatrogenic Pseudomona infections are common in pressure sores with occlusive dressings.
- Excessive moisture in and around the wound can lead to maceration and further skin breakdown.
- The best treatment for pressure sores is prevention. This means turning a person who is confined to a bed at least every two hours, to relieve pressure over bony prominences.
- Many products are available to keep pressure off bony prominence, such as alternating pressure mattresses, eggcrate mattresses, water beds, silicone gel beds, air floatation mattresses, or Stryker frames (for people with spinal injuries). Remember that none of these is a substitute for frequent turning.
- Friction and Shear also cause pressure sores. To prevent damage from friction and shear, avoid leaving the person rolled up in bed, avoid rubbing the person across the sheets, and use minimum turning sheets and incontinence pads.
- Help the wheelchair-bound person to shift his or her weight periodically to prevent pressure sores.
References/Bibliography for articles
- Bradley, M., Cullum, N., Nelson, E.A., Petticrew, M., Sheldon, T., & Torgerson, D. (1999). Systematic reviews of wound care management:
- Dressings and topical agents used in the healing of chronic wounds. Health Technology Assessment, 3(17, Part2), 1-135.
- Johnson, M., Maas, M., & Moorhead, S. (2000). Nursing Outcomes, Classification (NOC) (2nd. Ed.). St. Louis: Mosby.
- Merck Manual Online. (2001). Pressure Sores. Retrieved March 11, 2002. http://www.merck.com/pubs/mmanual/section10/chapter122/122a.htm.
- The National Decubitus Foundation. (2002). Cost savings through bedsore avoidance. Retrieved March 11, 2002. http://www.decubitus.org/cost/cost.html
- Wound Ostomy and Continence Society. (2001). OASIS Guidance Document. Retrieved March 11, 2002. http://www.wocn.org/PDF/WOCNOASISGuidance.pdf.
Pressure Sore Care Websites
- To explore the latest on pressure sore care, check out these websites:
National Pressure Ulcer Advisory Panel (NPUAP)
http://www.npuap.org/Default.htm
- Current research, newsletter, conferences, and information about pressure ulcers
Sepsis Bed Sore Pressure Ulcer – Learn more about bed sores, pressure sores, sepsis, decubitus ulcers, and pressure ulcers. Click here to find out more about nursing home abuse and your legal rights.
The National Decubitus Foundation
http://www.decubitus.org
Describes the great enigma of wound care: Medicare will not pay for their prevention, but will pay for special beds after a Stage III ulcer has developed.
Wound Care Information Network
http://www.medialedu.com/default.htm
Site maintained by two MDs: A. Freedline and T. Fishman; information based on National Guidelines
The Wound Care Society, from the UK
http://www.woundcaresociety.org/
Information about membership; clinical information available for purchase
Wound, Ostomy, and Continence Nurses Society
http://www.wocn.org/