“The problem of pressure ulcers is timeless. Despite increasing technology enabling us to diagnose and treat disease, few problems develop so quickly, persist so tenaciously and heal so slowly. In addition, perhaps no other problem is seen as a direct reflection of the quality of the nursing care the patient has received.”
(Pajik et al, 1989, Dealey, 1992)
A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure or shear and/or a combination of these.
Pressure ulcers, also known as decubitus ulcers, bed sores and pressure damage, are pressure injuries which can extend to underlying structures such as muscle and bone, areas of localised damage to the skin and/or underlying tissue.
In adults the damage usually occurs over bony prominences, such as the sacrum; they are believed to be caused by a combination of pressure, shear, friction and moisture.
If care is not taken, pressure ulcers can be serious. They can damage not just the skin but also the fatty tissue beneath the skin. Pressure ulcers may cause pain, or lead to a longer hospital stay. They can become infected, sometimes causing blood poisoning or bone infections. In severe cases, the underlying muscle or bone may be destroyed. In extreme cases pressure ulcers can become life threatening.
Pressure ulcers are caused by a combination of:
*Reproduced by kind permission of the Tissue Viability Society
Pressure ulcers are categorised by severity, from grade 1 to grade 4:
Grade 1: Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators particularly on individuals with darker skin.
Grade 2: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion or blister.
Grade 3: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.
Grade 4: Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.
A risk assessment should be carried out by a professional who has had special training in identifying people at risk of developing pressure ulcers.
The timing of the risk assessment will depend on the patient’s individual circumstances and condition but should take place within six hours of any admission to hospital. The findings of the risk assessment should always be documented in the patient’s medical records.
Every pressure care policy should include re-assessment. Re-assessment should be carried out at regular intervals or as and when the patient's condition changes. Risk assessment involves a multidisciplinary approach; It is not just a ‘nursing problem’. This involves maximum collaboration to ensure that the patient receives individual quality care. Staff must follow the individual working environments and employer’s pressure ulcer prevention policies.
There are many factors which increase the risk of a person getting pressure ulcers. They include:
Pressure ulcer management approaches and techniques are continuously developing and there remains no overall consensus about them. Over the past 30 years, a number of risk assessment tools and scales have been developed with the primary aim of identifying those individuals at risk of developing pressure ulcers. Pressure ulcer risk assessment tools represent an attempt to determine an individual’s risk status by quantifying a range of the most commonly recognised risk factors affecting the patient at a given time.
All individuals assessed as being vulnerable to pressure ulcers should, as a minimum provision, be placed on a high-specification foam mattress with pressure-redistributing properties.
Patients with a grade 1−2 pressure ulcer should - as a minimum provision be placed on a high specification foam mattress/cushion, and be closely observed for skin changes.
Patients with grade 3−4 pressure ulcers should - as a minimum provision be placed on a high specification foam mattress with an alternating pressure overlay, or a sophisticated continuous low pressure system, and the optimum wound healing environment should be created by using modern dressings. (NICE Guidelines)
The provision of pressure redistributing/relieving devices needs a 24 hour approach and consideration should be given to all surfaces used for the patient, whether lying or sitting.
The support surface and positioning needs should be assessed and reviewed regularly and determined by the results of skin inspection, patient comfort, ability and general state. Regular repositioning should occur even when individuals are using pressure relieving devices.
Pressure reduction/redistribution is achieved in a variety of ways. The simplest static systems rely on the ability of the materials used to conform to the body shape, for example foam which contours to the body. Alternatively the foam may be cut to allow it to move more freely and also increase the potential surface area, thus redistributing the patient’s body weight over a greater surface area. The support surface should be chosen for the individual after assessing their level of risk, their medical condition and should also be appropriate for their mobility, care needs and personal autonomy.
They include the following;
Dynamic mattress systems are powered by a control unit and work by cyclical application and removal of pressure. Different makes of equipment have different numbers of cells and time spans over which the cycles occur. Generally speaking it should be possible to test very simply for pressure relief by sliding a hand underneath the patient over a deflated cell. If this is possible then that area of the mattress is not supporting the patient’s weight and therefore pressure relief has been achieved. Alternating pressure care systems are available as full mattresses replacements which are put directly onto a bed frame base or overlay mattresses which are placed on top of a conventional mattress.
Cushions can be used on the chair base or wheelchair and others are placed on top of conventional seat cushions.
Decisions about which device to use should be based on cost considerations and an overall assessment of the individual. Holistic assessment should include all of the following:
The cost of pressure ulcers is largely unknown. To allow some clarification the Department of Health commissioned a report “The Cost of Pressure Ulcers”. Unfortunately, this report was solely concerned with the cost to the NHS; it only included hospitals and did not include any quality of life measures. Pressure ulcer related costs within the community is more difficult to assess.
It is estimated that 1 in 5 hospital inpatients has a pressure ulcer - this represents at least 20,000 hospital patients at any one time. In addition, many more individuals with a pressure ulcer are cared for at home or in residential and nursing homes. Around 400,000 people develop a new pressure ulcer annually in the UK. The cost to the NHS is high, primarily because of the need for prolonged hospital treatment in serious cases and the need to protect patients at risk - the annual cost is in the range of £1.8bn - £2.6bn. In terms of human cost, pressure ulcers seriously affect a person’s quality of life and can contribute to cause of death.