Pressure Ulcers: Risk Factors and Prevention

Pressure Ulcers Overview

• Pressure ulcers are lesions caused by pressure, friction, and/or shear, which results in damage to underlying tissue.
• Tissues over bony prominences are at the highest risk for pressure ulcers

Pressure Ulcers: Related Terms and Risk Factors

• Pressure ulcers may also be referred to as bed sores or decubitus ulcers.
• The elderly and those with spinal cord injuries are at the highest risk.
• 70% of all pressure ulcers occur in people older than 70 years of age.
• A healthy human, if left undisturbed in the same position, will develop pressure ulcers within 6-12 hours.
• The impacts of pressure ulcers include infection, death, pain, treatment concerns, and psychological concerns.

Healthy vs Compromised Skin

• Healthy skin contains a subcutaneous layer, containing blood vessels and cushioning fat
• The dermis is where new cells are produced.
• The epidermis is the outer covering that protects inner organs.
• Compromised skin has a subcutaneous layer with fewer and flatter fat cells, and also a dermis that produces cells more slowly
• Compromised skin has an epidermis that is dry and contains fewer layers of cells.

Internal Risk Factors

• Internal risk factors include increased age, disease processes, impaired immune system, poor nutrition, dehydration, edema, decreased sensation and mobility.

External Risk Factors

• External risk factors include poor resident handling techniques, pressure, friction, shearing, excessive moisture or dryness, urine/feces exposure, lack of barrier cream or moisturizer, and poor hygiene.

Areas Where Pressure Ulcers are Located

• When on the back, pressure ulcers are typically located on the heels, sacrum, elbow, shoulder, and back of the head
• 95% of pressure ulcers occur in the lower part of the body
• When lying on the side, pressure ulcers are typically located on the ankle, knee, hip area, shoulder, and ear.
• When sitting, pressure ulcers are located on the back of the upper and lower arm, hand, elbow, wrist, shoulder blades, spine, coccyx, hips, feet, heels, and toes.

Stage I Pressure Ulcer

• Stage I is characterized by a reddened, unbroken, non-blanchable reddened area.
• Non-blanchable areas do not have capillary blood displacement, i.e. it doesn't turn white when pressure is applied with a fingertip.
• If redness is unresolved in 30 minutes, closely monitor it for redness to subside within 24 hours after pressure removal

Stage II Pressure Ulcer

• Stage II is characterized by a distinct break in the skin or a blister.
• It may extend into the dermis, and is shallow, with minimal drainage, and painful.

Stage III Pressure Ulcer

• Stage III extends into the subcutaneous layer, and presents as a deep crater with drainage. Monitor for infection.
• Healing may take weeks to months.

Stage IV Pressure Ulcer

• Stage IV penetrates through the subcutaneous layer into underlying muscle, tendon and bone.
• Undermining or sinus tracks may occur
• Stage IV includes risk of infection, septicemia and osteomyelitis
• Stage IV can be life threatening

Staging Pressure Ulcers

• When an ulcer is too covered in dead tissue to see the wound bed, it is deemed unable to stage.

Venous Ulcers: Stasis Ulcers

• Venous Stasis ulcers occur when blood has difficulty returning to the heart via the veins
• Leaks out of the blood vessels into the tissue resulting in pitting edema.
• Stasis ulcers can be caused by inactivity, obesity, and varicose veins.
• The appearance of venous ulcers starts with skin that is shiny and stretched looking
• As the edema persists, the skin appears reddish brown, dry, leathery, and hard. Itching is common.
• Elastic TED stockings are an important step in preventing venous ulcers

Elastic or TED Stockings

• Elastic TED stockings exert pressure on the veins, promoting blood flow to the heart.
• TED stockings prevent life-threatening blood clots for residents with circulatory or heart disease.
• TED stockings are typically applied prior to getting out of bed for swelling prevention, and are removed according to the ADL
• These are typically washed by hand in the sink by RCA's
• TED stockings have an opening near the toes to check CWMS
• Never pinch elastic stockings to remove wrinkles, as this can tear the skin
• Remove all wrinkles by smoothing stocking with your hand

Arterial Ulcers

• Arterial Ulcers are caused by diseases or injuries that decrease arterial blood flow to the lower legs.
• Can be caused by Hypertension, Athlerosclerosis, Diabetes, Smoking, and natural narrowing of the arteries with aging.
• The appearance of arterial ulcers are legs that are cold to the touch
• The skin will appear blue and/or shiny.
• Arterial ulcers are commonly found on the tops/between toes, and on the outer sides of the ankle, and also common on the heels of residents placed on bed rest.

Management of Pressure Ulcers

• Good skin care includes moisturizers and barrier creams
• Turning, positioning, and maintaining good alignment every 2 hours is important
• Specialty mattresses and cushions are useful for at-risk residents.
• Utilize bed cradles, pillows, gel pads, padded bed rails, and sleeved clothing.
• Regularly check specialty chair cushions and bed surfaces for 'bottoming-out' due to lack of air.

Heel Pressure Relief

• Support the length of legs with pillows and allow heels to 'dangle' off the pillow edge.
• Limit the head of bed elevation to 30° or less.

Maximize Nutrition

• Report poor nutritional intake.
• Always offer and encourage fluids to residents
• A dietician may increase protein and calories

Reporting Wounds

• Report all reddened and open areas.
• Observe wound dressings and report if they are loose or leaking.