Sometimes students get confused with the word ulcer. The ulcer is a crack in the skin as well as mucous membrane including a drop of surface tissue. In pressure ulcers, the skin and underlying tissue get a localized injury. The injury occurs over a bony prominence due to the pressure.
Etiology of Pressure Ulcer:
The cause of pressure ulcers is the application of unrelieved pressure with huge force over a short time. It can obstruct the blood flow, halt the blood supply to the capillary network, and deprive the oxygen and nutrients level of the tissue. If the external pressure is greater than arterial capillary pressure then it causes tissue damage, inflow impairment, and resultant local ischemia. The most common site for pressure ulcers are:
- Heals
- Serum
- Ischial tuberosities
- Lateral malleoli
- Greater trochanters
What are the risk factors for pressure ulcers:
There are two types of risk factors .i.e. Intrinsic and extrinsic.
The intrinsic risk factors are:
- Limited mobility
- Pain
- Spinal cord injury
- Cerebrovascular accident
- Poor nutrition
- Diabetes mellitus
- Skin aging
The extrinsic risk factors are:
- Shear from any involuntary muscle movements
- Pressure from any hard surface .i.e. bed, wheelchair, stretcher.
- Shear from any involuntary muscle movements
- Excessive perspiration
- Wound drainage
- Bowel or bladder incontinence
What are the causes of pressure ulcers?
1. Moisture:
The moisture occurs due to excessive perspiration and incontinence. The moisture irritates and softens the skin which then develops the pressure ulcer. Moisture also reduces the tensile strength of skin which makes it vulnerable to mechanical damage from shear stress.
2. Shear:
Shear is produced when the skin moves in one direction and the underlying bone moves in another direction. It stretches and shreds cell walls as well as small blood vessels. Shear along with pressure develop the pressure ulcer.
3. Friction:
Slight rubbing or friction along with pressure may cause minor pressure ulcers.
4. Heat:
A rise in temperature along with rising in pressure makes the skin tissue vulnerable to injury from ischemia.
Risk of developing pressure ulcer:
The risk of developing pressure ulcers is high in those people who are suffering from these conditions:
- Decrease subcutaneous fat
- Loss of elasticity in collagen fiber
- Decrease of local blood supply to the skin
- Flat and thin epithelial layers
- Decrease tolerance to hypoxia.
Stages of pressure ulcer:
There are four stages in pressure ulcer and these are:
- Stage I
- Stage II
- Stage III
- Stage Iv
- DTI ( Deep Tissue Injury)
- Unstageable
Stage I:
We can identify stage I if the skin is intact with non-blanchable redness of a localized area over a bony prominence. The darkly pigmented skin does not contain visible blanching. Its color is different from the surrounding area.
Stage II:
There is loss of dermis and partial thickness in stage II. Skin presents as a shallow open with a red-pink wound bed and without slough. It may also present as an intact or open/ ruptured serum-filled blister.
Stage III:
In stage III, there is full-thickness tissue loss. The subcutaneous fat might be visible but bone, tendon, and muscle do not expose. Slough may be present and do not obscure the depth of tissue loss.
Stage IV:
In stage IV, the full tissue thickness is exposed with bone, tendon, or muscle. There may be the presence of slough on some part of the wound bed and sometimes include undermining and tunneling.
Deep Tissue Injury:
In deep tissue injury, there is the occurrence of purple or maroon localized area in discolored intact skin or blood-filled blisters. It happens due to the damage of underlying soft tissue from pressure or shear.
Unstageable:
In unstageable, there is the loss of full-thickness tissue. The base of the ulcer will be covered with slough or eschar in the wound bed.
Management of pressure ulcers at different stages:
Management of clean ulcer without cellulitis in different stages:
Stage I:
In stage I, we need to apply protective dressing as needed.
Stage II:
We need to clean the wound in stage II and also we will have to apply the moist dressing .i.e. transparent film.
Stage III and IV:
If there is no necrotic tissue in stages III & IV then we need to clean the wound and also apply the moist to absorbent dressing .i.e. foam, alginate, and hydrogel. If there is no improvement in 14 days, then we can go for topical antibiotics.
If there is necrotic tissue in stages III &IV, then we need to perform sharp debridement. If sepsis or advancing cellulitis is present then autolytic, enzymatic, or mechanical debridement is preferred.
How do we reduce and prevent pressure ulcers?
We can reduce and prevent pressure ulcers by repositioning and using support surfaces. The other interventions we can use are:
- Antibiotics
- Healthy diet
- Managing the pain
- Managing the incontinence
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