pressure ulcers

23 Jul

Pressure ulcers are areas of soft tissue that are compressed due to pressure/ force, causing impaired circulation which leads to different stages of ulceration (1 being mild and 4 being severe). The patches of area become discoloured, painful and can sometimes lead to ulceration. Reasons for pressure ulcers range from immobility, increased age and undernutrition.

- Globally, the incidence of pressure ulcers ranges between 0-72% in healthcare settings [1]
- In the UK, over 700, 000 people are affected by pressure ulcers each year [2]
- Most prevalent in long-term acute care facilities (hospitals that manage serious medical conditions that require intense, specialised treatment) with 23-27%
- Known to affect around 3 million people in the US
- Overall prevalence of pressure ulcers in hospitalised patients has been found to be between 5-15% [3]
- Constant pressure or friction applied to one area of the body- causing blood to stop flowing normally leading to skin break down
- Being unable to move around and staying in one position for a long time.
- Being bedridden or in a wheelchair increases the risk of pressure sores [4]
Medical Students
- Final common pathway is ischemia and necrosis due to sustained pressure impairing perfusion.
- Pressure >32 mmHg impairs arterial inflow, while >8–12 mmHg impairs venous return.
- Tissue tolerance depends on duration and pressure intensity:
  - Superficial dermis tolerates ischemia for 2–8 hours.
  - Deeper tissues (muscle, fat, connective tissue) can tolerate <2 hours due to higher oxygen demands.
- Early tissue damage often occurs beneath intact skin, leading to an inverted cone-shaped ulcer.
- Friction contributes by damaging superficial skin layers.
- Moisture (e.g., from sweat, incontinence) worsens skin breakdown via maceration and barrier disruption.
Patients
- Pressure ulcers happen when constant pressure cuts off blood supply, causing tissue damage or death.
- When pressure is too high for too long, it blocks blood flow into and out of the skin and tissue.
- Surface skin may last 2–8 hours without oxygen, but deeper layers can be damaged in as little as 2 hours.
- You might not see damage on the skin surface, but the tissue underneath may already be harmed.
- The damage can be shaped like a cone, wider underneath than on the skin.
- Friction (skin rubbing on bed sheets or clothing) can tear the top skin layers.
- Moisture (from sweating or leaks) can soften and weaken the skin, making ulcers worse. [5]
- Reduced mobility
- Nutritional deficiency
- Conditions such as diabetes and peripheral vascular disease that causes poor blood flow to sites of pressure
- Older age
- Poor posture or deformity [6]
- Can be stages 1-4:
  - Stage 1- mild injury with intact skin and redness (without white discolouration under pressure). Dark skin can fail to present the injury. The areas of injury are warmer, cooler, softer and firmer than non-affected tissue
  - Stage 2- more deep injury with a red/pink base and loss of epidermis (layer of skin) causing erosions or blisters
  - Stage 3- ulcer formation with full skin loss that extends to the fascia (a couple of skin layers deep) which are crater like in appearance
  - Stage 4- severe injury with full-thickness loss of the skin layers, including the destruction of the skin, tissue death and damage to muscles, tendons, bones.
- Deep tissue pressure injury- intact/non-intact skin to the area of damage due to pressure or force applied to the skin. This presents with dark/maroon discolouration and blood-filled sacs (bullae)
- Medical device pressure injury- caused by casts or splints that lead to the injury fitting the pattern of the device [7]
- Clinical examination which looks at the appearance of the patient and features of pressure ulcers
- Blood tests can be carried out to suggest osteomyelitis (an infection of the bone) using erythematous sedimentation rate and white blood cell count.
- Serum glucose can be used to exclude diabetes
- Deep tissue biopsy (taking a sample of skin from the deeper layers of the skin) to diagnose infection
- An MRI scan used when bones are involved- does not confirm pressure injury [8]
- Diabetic foot ulcer
- Damage to the skin caused by moisture
- Osteomyelitis- infection of the bone
- Malignancy on the skin
- Peripheral arterial disease- affecting the arteries of the hands/feet
- Venous ulcers- sores formed in the skin [6]
Medical Students
- Pressure relief is central to management: involves positioning, protective devices, and support surfaces.
- Repositioning schedules are essential for documentation and consistency.
- Bedridden patients: reposition every 2 hours, ideally at a 30° lateral tilt.
- Chair-bound patients: reposition every hour.
- Use protective padding (pillows, foam wedges) to offload pressure from high-risk areas.
- Support surfaces:
  - Static: foam, air, gel, water overlays/mattresses.
  - Dynamic: alternating-air, low-air-loss, and air-fluidized mattresses.
  - Reduce shear forces through proper technique and supportive equipment.
Medications and Wound Care
- Pain management:
  - Use NSAIDs or acetaminophen for mild to moderate pain.
- Friction reduction:
  - Apply barrier protectants (e.g., petroleum jelly) especially under medical devices or PPE.
- Wound care components:
  - Cleaning: normal saline or pressurized irrigation.
  - Debridement: remove necrotic tissue via: Mechanical, surgical, autolytic, or enzymatic techniques.
  - Dressings:
    Should maintain a moist wound environment.
    Tailor type based on ulcer stage and exudate volume.
Patients
- Reducing pressure is key to healing pressure ulcers.
- Stick to a schedule for moving and changing positions:
  - If you're bedridden, turn every 2 hours and lie at a 30° angle when on your side.
  - If you're in a chair, shift position every hour.
- Use soft supports (like pillows or foam wedges) under vulnerable areas.
- Special mattresses help reduce pressure:
  - Static mattresses don’t move and include foam, air, or gel options.
  - Dynamic mattresses move and include air-filled systems that adjust pressure.
- For pain, you can use painkillers like paracetamol or ibuprofen.
- Protect your skin from rubbing with barrier creams like petroleum jelly.
- Wound care includes:
  - Cleaning with saltwater (saline) or gentle flushing.
  - Removing dead tissue (called debridement) with tools, surgery, or special gels.
  - Using the right type of dressing to keep the wound clean and help it heal—this depends on how deep or wet the ulcer is. [7]
- Cellulitis- infection of the tissue
- Blood poisoning- infection from the ulcers can spread to other parts of the body as well as the blood
- Bone and joint infections from ulcer formation
- Necrotising fasciitis (tissue death) that can be very serious- caused by bacteria such as Group A streptococci
- Gas gangrene- serious conditions that cause the ulcer to become infected with clostridium bacteria [8]
- Pressure injuries can be prevented if you turn every two hours
- Pressure ulcers are only found in cases of patients in care homes
- Pressure ulcers are inevitable in elderly and for those with poor nutrition [9,10]
- What is the best way to take care of pressure ulcers?
- How often do pressure sores need to be looked at?
- What positions are advised to prevent ulcers forming?
- How do I get support for the maintenance of pressure ulcers?
- How long will treatment take to be effective in managing the symptoms of pressure ulcers?
- NICE guidelines
- NHS Inform
- Skill for Care
[1] https://internationalguideline.com/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711432/
[3]https://www.sciencedirect.com/science/article/abs/pii/S0190962219300921#:~:text=Pressure%20ulcers%20were%20most%20prevalent,and%20similar%20across%20facility%20type
[4] https://www.cancerresearchuk.org/about-cancer/coping/physically/skin-problems/pressure-sores/causes-and-prevention
[5] https://www.physio-pedia.com/Pressure_Ulcers#:~:text=of%20their%20hospitalization-,Pathophysiology,tissue%20for%20an%20extended%20period.
[6] https://cks.nice.org.uk/topics/pressure-ulcers/background-information/risk-factors/
[7] https://www.msdmanuals.com/en-gb/professional/dermatologic-disorders/pressure-injury/pressure-injuries?query=pressure%20ulcers
[8] https://bestpractice.bmj.com/topics/en-gb/378/investigations#toConsider
[9] https://www.skilledwoundcare.com/post/the-top-myths-about-pressure-injuries
[10] https://aymes.com/blogs/disease-related/myth-busting-protein-and-pressure-ulcers