Pressure Ulcers and Its Management

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A pressure ulcer is localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of sustained pressure, or pressure in combination with shear and/or friction. (

Sustained pressure: When the skin and underlying tissue is trapped between the bone and a surface (such as a wheelchair or bed), the pressure may be greater than the pressure of blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to the tissues. Deprived of these essential nutrients, cells of the skin and other tissues are damaged and may die.

Friction: Friction is resistance to motion. Friction may occur when the skin is dragged across a surface (e.g. when turning a patient). The resistance to motion may be even greater if the skin is moist. Friction between the skin and another surface may make fragile skin more vulnerable to injury.

Shear: Shear occurs when two surfaces move in the opposite direction. This motion may damage tissue and blood vessels, making the site more vulnerable to damage from sustained pressure. (E.g. when a bed is elevated at the head, a person can slide down in bed). As the tailbone moves down, the skin over the bone may stay in place, essentially
pulling in the opposite direction.

Risk factors for developing pressure ulcers

1)  Age and gender: Especially for older female adults, their skin is more fragile, thinner, drier and less elastic. This group of people is therefore at much higher risk of developing pressure ulcers compared to older male groups.

2)  Weight loss: As the loss of fat and muscle results in less cushioning between bones and a bed or wheelchair.

3)  Bed or chair bound conditions (e.g. comatose, paralysed, terminally ill).

4)  Inability to move or unable to change position without help (e.g. post major surgery or trauma, hip fracture, morbid obesity).

5)  Urinary or fecal incontinence creates moisture which irritates the skin.

6)  Excessive moisture (perspiration) or dryness increases friction between skin and clothing/bedding.

7)  Poor nutrition & hydration: Fluids, calories, proteins, vitamins & minerals are needed for maintaining healthy skin and prevent tissue breakdown.

8)  Medical conditions affecting circulation (e.g. diabetes mellitus, vascular diseaseswhere inadequate blood flow increases risk of tissue damage.

9)  Decreased mental awareness (e.g. due to Alzheimer’s disease): Certain medications that affects awareness level, traumas which affects awareness level (e.g. due to accidents) where one is unable to act in prevention of pressure ulcers.
10)  Lack of sensory perception due to spinal cord injuries, neurological disorders (e.g. multiple sclerosis, strokes), resulting in loss of sensation. People with these conditions are unable to feel pain/discomfort. This results in one not being aware of bedsore developments or the need to change position.

Stages of Pressure Ulcers and its Characteristics

Stage 1: Defined as intact skin with non-blanchable redness of localised area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Stage 2: Defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. It may also present as an intact or open or ruptured serum filled blister. It is presented as a shiny or dry shallow ulcer without slough or bruising.

Stage 3: Defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining or tunnelling wound. Bone or tendon is not visible or directly palpable.

Stage 4: Defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining or tunnelling. Stage 4 ulcers can extend into muscles and/or supporting structures, (e.g. fascia, tendon or joint capsule). Exposed bone or tendon is visible or directly palpable.

All 4 stages of pressure ulcers are illustrated with the pictures above. It is appropriate to identify the stage of pressure ulcer one is having. By identifying the stage, we will know how to manage it. Stage one (characterised by redness alone) is the prime indicator which tells a caregiver that this person is at high risk of developing pressure ulcers soon. The rest of the stages may require treatment such as placing dressings to manage it, either at home or in the clinics/hospitals, as prescribed by health care givers.

Next we will discuss the prevention strategy for pressure ulcers. If an individual already suffers from pressure ulcers, the strategies that are to be discussed here still apply to him / her. By following the prevention strategy below, further development of other pressure ulcers can be prevented.

Prevention Strategy for Pressure Ulcers
Inspect high risk individuals’ skin daily. Observe and monitor all pressure points (especially all bony areas and skin folds). Pay special attention to the reddened areas, that when pressed, do not turn white.

Optimise nutrition and hydration to assist in the process of wound healing by providing a high protein and high calorie diet (patients who suffer from some diseases that prevent them from consuming such a diet, please consult with a medical doctor first).

Minimise pressure with physical repositioning or a stringent 2-hourly turning. Doing a proper strict 2-hourly turning is very effective in preventing pressure ulcer from developing. A proper positioning is as illustrated in picture below. You need to put pillows at back, between legs and between hands, to prevent friction from other bony structures. You need to do repositioning every 2 hours, alternating in different positions of right lateral, left lateral, supine or back and prone position. 

If there is no contraindication for sitting up, then you can sit up the individual on the bed or wheelchair for 2 hours as well. However, some patients may not tolerate a sitting position for 2 hours. In this case, you may let the individual sit up on the bed or wheelchair for at least 30 minutes or 1 hour. Otherwise, wheel the individual around on a wheelchair for 30 minutes or so to divert his or her attention.

Reduce friction during turnings by lifting the patient instead of dragging. Friction can rub off the top layer of the skin and damages blood vessels under it. Therefore it is better to use a lifter (which has been specifically designed to lift a person) or any long cloth sheets which are applied underneath patients’ body to use it as a lifter. You will need at least 2 people to lift someone who is unable to move with one person at each side. The two people performing the lifting and turning must remember to keep their backs straight. This is to protect the lifters from any potential back injury.

Pillows or wedges can be used to keep knees or ankles from touching each other. Maintain good posture and comfort. Avoid prolonged sitting or lying on the back without being moved. Avoid using doughnut-shaped rings and water-filled gloves as they reduce blood flow, thus causing body tissues to swell. Avoid vigorous massaging of skin over bony parts of body as massages may squeeze and damage the tissues under the skin.

For non-ambulatory individuals with diaper, check their diapers every 2 hours to ensure that they are not soaked in urine or faeces for long hours. Clean the individuals’ skin thoroughly after each defecation/urination.  Daily hygienic bath is important to maintain skin       cleanliness using non-irritating soap/lotion. Manage moisture by keeping the skin dry and
moisturise the skin with barrier creams or lotions. Use items that can help reduce pressure,
e.g. pillows, sheepskin, foam padding, and powders. Baby powders also contain corn starch, which can be sprinkled onto the bedsheet to help reduce friction. Otherwise, you can even apply a thin layer of pure corn starch onto the bedsheet to prevent friction.

Medication for Prevention of Pressure Ulcers
There is also medication for the prevention of pressure ulcers, e.g. Sanyrene (Corpitolinol 60). It contains hyperoxygenated oil of essential fatty acids in a single packing of 20ml spray bottle. The indications are for the prevention of pressure sore, improvement of micro-circulation, prevention of skin dehydration, strengthens skin resistance, increases cellular renewal and indicated for redness disappearing at finger pressure.

Directions for use: Spray once onto the pressure areas at risk of developing pressure ulcers (only for stage 1 pressure ulcers. Stage 1 means only redness is noted. This treatment cannot be used for stage 2, 3, and 4 pressure ulcers). Gently apply the medication using fingertips for one minute. Repeat application on each area 2 to 3 times per day. You may purchase this medication from your local pharmacies or hospitals. This treatment has been proven effective for many older adults. There are individuals with bedridden conditions for more than 10 years and did not develop any open pressure sores as their caregivers at home diligently apply this treatment for many years as prescribed. Of course, this treatment goes hand-in-hand with a strict 2-hourly turnings as well.

Practising all the prevention methods as discussed above will definitely help in further deterioration of the skin breakdown in high-risk individuals.

Related articles:
Epileptic Seizure Management at Home
Management of Gout and Hyperuricemia
Is Your Child Suffering From Febrile Convulsion?

Author: Sudha Karuppiah

Copyright © 2012 Sandhya Maarga Holistic Living Resources
Holistic Living Annex (NOVEMBER 2012)

1 Response for “ Pressure Ulcers and Its Management”

  1. Longman says:

    This is a very good article! Applies particularly for our elderly parents. All children with ill parents should learn these tips.


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