Pressure Ulcer Development: A Comprehensive Guide for Nurses

Pressure ulcers, also known as pressure injuries, decubitus ulcers, or bedsores, are localized injuries to the skin and underlying tissue, typically over bony prominences, resulting from prolonged pressure, shear, or friction. They are a significant concern in healthcare settings due to their impact on patient morbidity, mortality, and healthcare costs. Nurses play a crucial role in the prevention, early detection, and management of pressure ulcers.

Pathophysiology

Pressure ulcers develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period, leading to:

• Ischemia: Prolonged pressure exceeds capillary closing pressure (approximately 32 mmHg), reducing blood flow and oxygen delivery to tissues.
• Hypoxia and Nutrient Deprivation: Decreased perfusion leads to cellular metabolism disruption.
• Tissue Necrosis: Prolonged ischemia causes cell death and tissue breakdown.
• Inflammation: Damaged cells release inflammatory mediators, further contributing to tissue injury.

Shear and friction exacerbate tissue damage:

• Shear: Occurs when the skin remains stationary, and underlying tissues shift, causing blood vessels to stretch and occlude.
• Friction: Results from rubbing the skin against a surface, leading to superficial skin damage.

Risk Factors

Intrinsic Factors:

• Immobility: Limited ability to reposition oneself due to paralysis, sedation, or weakness.
• Sensory Impairment: Reduced sensation prevents awareness of discomfort signaling the need to change position (e.g., neuropathy, spinal cord injury).
• Age: Elderly patients have thinner skin and decreased elasticity.
• Poor Nutrition and Hydration: Malnutrition and dehydration impair skin integrity and healing.
• Medical Conditions: Diabetes mellitus, vascular diseases, and hypotension decrease tissue perfusion.
• Incontinence: Moisture from urine or feces can macerate the skin.
• Altered Mental Status: Confusion or decreased consciousness reduces mobility and awareness.

Extrinsic Factors:

• Pressure: Prolonged pressure over bony prominences (e.g., sacrum, heels, elbows).
• Shear and Friction: Incorrect positioning, transferring, or dragging patients.
• Moisture: From perspiration, wound drainage, or incontinence.

Common Sites for Pressure Ulcers

• Occiput (back of the head)
• Shoulder blades
• Elbows
• Sacrum and Coccyx
• Hips
• Heels
• Ankles

Stages of Pressure Ulcers

According to the National Pressure Injury Advisory Panel (NPIAP), pressure ulcers are categorized into the following stages:

1. Stage 1: Non-Blanchable Erythema
   • Intact skin with localized redness that does not blanch (lose redness) when pressed.
   • May be warm, edematous, firm, or painful.
2. Stage 2: Partial-Thickness Skin Loss
   • Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.
   • May also present as an intact or open/ruptured serum-filled blister.
   • No slough (dead tissue) is present.
3. Stage 3: Full-Thickness Skin Loss
   • Full-thickness tissue loss involving damage or necrosis of subcutaneous tissue.
   • Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.
   • Slough may be present but does not obscure the depth of tissue loss.
   • May include undermining and tunneling.
4. Stage 4: Full-Thickness Tissue Loss
   • Full-thickness tissue loss with exposed bone, tendon, or muscle.
   • Slough or eschar (dead tissue) may be present on some parts of the wound bed.
   • Often includes undermining and tunneling.
5. Unstageable: Depth Unknown
   • Full-thickness skin or tissue loss where the base of the ulcer is covered by slough or eschar.
   • Until enough slough or eschar is removed to expose the base, the true depth, and therefore stage, cannot be determined.
6. Deep Tissue Pressure Injury: Depth Unknown
   • Persistent non-blanchable deep red, maroon, or purple discoloration of intact skin.
   • May present as a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Assessment

Initial Assessment:

• Skin Inspection: Perform head-to-toe examination, focusing on bony prominences.
• Risk Assessment Tools: Utilize standardized tools such as the Braden Scale or Norton Scale.

Braden Scale Parameters:

• Sensory Perception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction and Shear

Scoring: Each category is scored from 1 to 4 (except friction and shear, which are scored 1 to 3). The total score ranges from 6 to 23.

Interpretation:

• Mild Risk: 15–18
• Moderate Risk: 13–14
• High Risk: 10–12
• Very High Risk: ≤9

Ongoing Assessment:

• Regular Reassessment: Frequency depends on the patient's condition (e.g., daily in acute care).
• Documentation: Detailed records of skin condition, ulcer characteristics (size, depth, appearance), and interventions.

Prevention Strategies

1. Positioning and Mobilization

• Repositioning Schedule: Turn patients at least every 2 hours in bed; every 15 minutes if sitting.
• Positioning Devices: Use pillows, wedges, or foam pads to offload pressure from bony prominences.

2. Avoid Shear and Friction

• Use lift sheets or transfer devices; avoid dragging patients.

3. Head of Bed Elevation

• Keep at the lowest degree consistent with medical condition (usually ≤30 degrees) to reduce shear.

4. Skin Care

• Keep Skin Clean and Dry: Manage moisture from incontinence, perspiration, or wound drainage.
• Use Mild Cleansers: Avoid harsh soaps; pH-balanced cleansers are preferred.
• Moisturize: Apply moisturizers to prevent dryness and cracking.
• Inspect Skin Daily: Pay special attention to high-risk areas.

5. Nutritional Support

• Assess Nutritional Status: Monitor weight, albumin, prealbumin levels.
• Dietary Intake: Ensure adequate protein, calories, vitamins (especially vitamin C and zinc), and hydration.
• Consult Dietitian: For individualized nutritional plans.

6. Support Surfaces

• Mattresses and Overlays: Use pressure-reducing mattresses or overlays (foam, gel, air, or alternating pressure).
• Cushions: Provide appropriate cushions for chairs or wheelchairs.

7. Education

• Patient and Family: Teach about the importance of repositioning, skin care, and nutrition.
• Healthcare Team: Ensure all staff are aware of prevention protocols.

Management of Existing Pressure Ulcers

Wound Care Principles:

• Assessment: Regularly evaluate ulcer size, depth, exudate, and signs of infection.
• Cleaning: Use normal saline or appropriate wound cleansers; avoid cytotoxic agents (e.g., hydrogen peroxide).

Debridement:

• Autolytic Debridement: Uses body's own enzymes with moisture-retentive dressings.
• Enzymatic Debridement: Topical application of enzymes.
• Mechanical Debridement: Wet-to-dry dressings (used less frequently due to tissue damage).
• Surgical Debridement: Performed by qualified healthcare professionals for extensive necrosis.

Dressings:

• Transparent Films: For shallow wounds with minimal exudate.
• Hydrocolloids: Maintain moist environment for partial-thickness wounds.
• Hydrogels: Provide moisture for dry wounds.
• Foams: Absorb moderate to heavy exudate.
• Alginates: For wounds with heavy exudate; derived from seaweed.

Infection Control:

• Monitor for signs of infection: increased pain, redness, warmth, purulent discharge, fever.
• Use topical or systemic antibiotics as prescribed.

Pain Management:

• Administer analgesics prior to dressing changes.
• Use non-pharmacological methods as adjuncts.

Adjunct Therapies:

• Negative Pressure Wound Therapy (NPWT): Applies controlled suction to promote healing.
• Hyperbaric Oxygen Therapy: Enhances oxygen delivery to tissues.
• Electrical Stimulation or Ultrasound: May promote wound healing.

Nursing Interventions

1. Assessment and Monitoring:

• Regular Skin Checks: Inspect skin each shift or per facility protocol.
• Documentation: Record findings meticulously, including location, size, stage, appearance, and interventions.

2. Implementation:

• Repositioning: Assist with scheduled turning and ensure proper body alignment.
• Skin Care: Perform hygiene care, manage moisture, and apply barrier creams as needed.
• Nutrition: Encourage adequate intake, monitor meal consumption, and collaborate with dietary services.
• Education: Teach patients and caregivers about pressure ulcer prevention and care.

3. Collaboration:

• Multidisciplinary Team: Work with wound care specialists, dietitians, physical therapists, and physicians.
• Care Planning: Develop individualized care plans based on risk assessment.

4. Evaluation:

• Monitor Outcomes: Evaluate the effectiveness of interventions.
• Adjust Plan of Care: Modify strategies based on patient response and progress.

Documentation

• Accurate Records: Essential for continuity of care, legal protection, and quality improvement.
• Include:
  • Date and time of assessment.
  • Risk assessment scores (e.g., Braden Scale).
  • Description of skin condition or ulcers.
  • Interventions implemented.
  • Patient's response and outcomes.

Legal and Ethical Considerations

• Standard of Care: Adhere to established guidelines to minimize liability.
• Informed Consent: Ensure patients or guardians understand treatment plans.
• Confidentiality: Maintain patient privacy in documentation and communication.

Prevention of Pressure Ulcers: Key Points

• Early Identification: Use risk assessment tools upon admission and regularly thereafter.
• Consistent Application of Protocols: Implement evidence-based guidelines diligently.
• Patient-Centered Care: Tailor interventions to individual needs and preferences.
• Continuous Education: Stay updated on best practices and emerging research.

Conclusion

Pressure ulcers are a preventable and manageable condition that significantly impacts patient quality of life and healthcare resources. Nurses are at the forefront of prevention and management efforts. Through diligent assessment, proactive interventions, patient education, and interdisciplinary collaboration, nurses can greatly reduce the incidence of pressure ulcers and promote optimal healing for existing wounds.