Pressure
ulcers, also called decubitus ulcers
(the term ¡§ Decubitus ¡¨ comes from
the Latin term ¡§ to lie down ¡¨ ) or
bedsores, are the end results of constant
skin pressure. A pressure ulcer is
an injury caused by unrelieved pressure
that damages the skin and the underlying
tissue. Pressure ulcers are a common,
life-threatening, expensive problem
for patients. Pressure ulcers have
been estimated to be responsible for
60,000 deaths per year in the United
States. 4% to 14% of hospitalized
patients develop pressure sores. They
occur quite commonly in the intensive
care unit (ICU) because of poor nursing
care, but even more commonly in extended
care facilities such as nursing home
and are especially common in the elderly.
Unrelieved
pressure on the skin squeezes tiny
blood vessels, which supply the skin
with nutrients and oxygen. When skin
is starved of nutrients and oxygen
for too long, the tissue dies and
a pressure ulcer forms. In animal
studies, 60 mmHg pressure applied
to the skin for one hour produces
histologically identifiable injuries
such as venous thrombosis, muscle
degeneration, and tissue necrosis.
The average human being exerts 60
to 70 mmHg pressure on such body areas
as the sacrum, occiput and heels while
lying in bed or on the ischia while
sitting in a chair. Decubitus ulcers
are caused by pressure exerted on
the subcutaneous tissue and skin when
compressed between the weight of the
body and a mattress or chair. The
pressure affects capillary perfusion
and interrupts the blood supply, producing
ischemia and preventing the removal
of cellular waste. When the pressure
is unrelieved, cell necrosis may occur.
Healthy people, however, regularly
shift their body weight, even while
asleep. Sitting in one position causes
pain in areas of increased pressure,
thus stimulating movement. Patients
unable to sense pain or to shift their
body weight, such as paraplegics or
bedridden individuals, develop prolonged
elevated tissue pressure and, eventually,
necrosis. Muscle tissue is more sensitive
to ischemia than the overlying skin.
That¡¦s why the necrotic area is always
wider and deeper than it appears on
first inspection.
Other
factors cause pressure ulcers
too. If a person slide down
in the bed or chair, blood vessels
can stretch or bend and cause
pressure ulcers. Even slight
rubbing or friction on the skin
may cause minor pressure ulcer.
Where Pressure Ulcers Form
Pressure
ulcers form where bone causes the
greatest force on the skin and the
tissue and squeezes them again an
outside surface, such as, other body
parts, a mattress, or a chair. For
persons who must stay in beds they
easily develop increased pressure
over bony prominences; the most common
sites are the sacrum and coccyx (hip),
the back of the head (occiput), behind
the ear, the scapular spines (shoulder),
the iliac crest, trochanter, anterior
knees, heels, costal margins and the
elbow.
For
patients in sitting position,
i.e., in chairs or wheelchairs,
are at risk for developing
pressure ulcers over the knees,
ankles, shoulder blades, back
of the head, and spine. These
areas are not covered by pads
of fat that normally cushion
blood vessels. When blood
vessels are compressed and
blood flow is reduced, oxygen
supply diminishes, skin breaks
down, the tissues beneath
are destroyed and pressure
ulcers occur. Pressure ulcers
are also likely to occur if
an area is continually moist
or not kept clean, such
as perineum, therefore, it
is very important to keep
the body dry and clear when
caring the incontinent and
bedridden patients.
Nerves
normally tell the body when to move
to relieve pressure on the skin. Persons
in bed who are unable to move may
get pressure ulcers after as little
as one to two hours. Persons who sit in
chairs and cannot move can get pressure
ulcers in even less time since the
pressure on the skin is greater.
The Risk Factors For Developing Pressure Ulcers
Confinement
to bed or chair, unable to move,
loss of bowel or urinary incontinence,
poor nutrition, and lowered
mental awareness are risk factors
to develop pressure ulcers.
The Stages Of Pressure Ulcers
Pressure
ulcers can be classified as superficial
or deep. Superficial ulcers may be
subdivided into four stages that are
useful in planning effective treatment.
Deep
pressure ulcers develop in tissues
under the skin and tend to occur in
response to shearing forces. Necrosis
begins beneath the skin rather than
in the epidermis, as described in
the development of superficial decubitus
ulcers. Deep ulcers may present initially
as blisters that change into eschars.
The lesion itself may be well developed
before any signs are visible. Typical
signs of pressure ulcers include a
hard mass under the skin and purplish
discoloration of the skin area subjected
to pressure. The amount of tissue
damage is usually much more extensive
than indicated by the amount of skin
area involved.
Risk
Assessment Scale System
The
Risk Assessment Scale System is basically
referred to The Waterlow Pressure
Sore Prevention Treatment Policy and
The Trial Pressure Sore Risk Assessment
Scale of Watkinson. The system is
intended to help guide treatment and
preventive measures. The system is
also aiming to design a risk assessment
scale, which included guidelines on
appropriate equipment selection, appropriate
dressings selection and classification
of the pressure ulcers in an attempt
to improve consistency of use.
Parameters
Findings
Points
Sex
Female
2
Male
1
Age
14 ¡V 49
1
50 ¡V 64
2
65 ¡V 74
3
75 ¡V 80
4
¡Ù 81
5
Body Mass Index (BMI)*
20 ¡V 25 (Acceptable)
0
26 ¡V 30 (Overweight)
1
¡Ù 31 (Obese)
2
¡Ø 19 (Underweight)
3
Appetite
Average
0
Poor
1
Nasogastric (NG) tube
2
Fluids only
2
Nothing but mouth anorexic
3
Continence
Complete (Urine and stool)
0
Catheterized and continent feces
0
Occasionally incontinent
1
Catheterized and incontinent feces
2
Doubly incontinent
3
Mobility
Fully
0
Restless or fidgety
1
Apathetic
2
Restricted
3
Inert or in traction
4
Chair-bound
5
Skin type visual appearance in risk areas
Healthy
0
Tissue paper
1
Dry
1
Edematous
1
Clammy
1
Discolored
2
Broken spot
3
Special Risk Factors
Findings
Points
Terminal cachexia
8
Cardiac failure
5
Peripheral vascular disease
5
Anemia
2
Smoking
1
Neurological deficit
Moderate
4
Moderate to severe
5
Severe
6
Major surgery or trauma
Orthopedic below waist or spinal
5
On table over 2 hours
5
Medication
Steroids/ cytotoxic agents/ high dose anti-inflammatory agents
4
*The Body Mass Index (BMI) = (Weight in kilograms) / (Height in meters)2
Score = SUM (points for parameters)
+ SUM (points for special risk factors)
Score = Sum of (Points for parameters) + Sum of (Points for special risk factors)
Interpretation:
Minimum score: 0
Maximum score: > 45
(The maximum score could be either 24 + 0 = 24 (No special risk factor scored) or
24 + 36 = 60 (All special risk factors scored).
The higher the score the greater risk it is to develop a pressure ulcer
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