Pressure Ulcers Explained by our very own Dr. William King

Hello, I am Dr. William King, a Board Certified Internal Medicine Physician in Private Practice

 I would like to tell you about the prevention, management and care of pressure ulcers, a condition more commonly known as bedsores.

Pressure ulcers are injuries to the skin caused by weight and pressure between the surface and bone.

Pressure ulcers are caused by immobility, poor nutrition, and loss of subcutaneous tissue.

2.5 million patients are affected by pressure  ulcers each year. The cost of treating pressure ulcers is 2.5 times the cost of prevention.

Pressure ulcers cost $9 billion to $13 billion per year.

The cost of individual patient care ranges from approximately $21,000 to $152,000 per pressure ulcer.

In 2007, Medicare estimated that each pressure ulcer added approximately $43,000 to a hospital stay.

More than 17,000 lawsuits are related to pressure ulcers annually.  That is the second most common claim after wrongful death.

60,000 patients die each year as a direct result of pressure ulcers.

The prevalence rate of pressure ulcers in long term nursing care facilities is estimated to be about 20% to 25%.  Pressure ulcers have been linked to the direct cause of death in 7% -8% of all paraplegics.  However, the prevalence rate has been decreasing over the years among bedridden patients through intervention and the use of pressure reducing methods and increased mobilization.

At the end of the day, pressure ulcers are cheaper to prevent than to treat.

Pressure ulcers lead to increased pain, mortality and infection and possible loss of body limbs.

Bedbound patients should be repositioned every two hours using pillows or foam wedges placed under the calf at the knees and ankles to prevent pressure at those sites, particularly when the patient is paralyzed.  Heel pressure can develop infections.  For people who are homebound or in wheelchairs, posture is very important to distribute the weight equally, reducing pressure on the sacrum and the coccyx.  Support systems such as having a trapeze attached to the bed so that the patient can use to assist in pulling; helps reduce friction and shearing.  There are special mattresses—low air loss beds to distribute the patient’s weight evenly, reducing friction.  There are overlays to place over the mattresses that prevent compression between the surface the patient is lying on and the bone in the body.

There are four stages of pressure ulcers or bed sores that range from a focal mild redness of the skin to a deep ulceration of the skin.

Stage 1: The skin is reddened.  When you press on the area that’s reddened, it doesn’t blanche.  Usually, when you press on an area of the skin, it turns white, and then it moves back to its regular color.  Sometimes the area of the skin can be warmer and it can feel either firmer or softer than the area around it.  So, the main thing about Stage 1 is that the bedsores or pressure ulcers are not open wounds.

Stage 2 is when the skin opens and begins to wear away.  The bedsores or pressure ulcers are usually painful. Sometimes it looks like a blister, other times it looks like a shallow crater or an ulcer.  Stage 2 is when the damage extends beyond the first layer of the skin.

In Stage 3 the area gets worse because it goes down deeper.  If it goes down into the derma you will see yellowish fat but not muscle, tendon, or bones.

In Stage 4, the ulcer is very deep.  The ulcer reaches the muscle or the bone and is sometimes associated with infections.  Stage 4 may also reach the eschar which is the black area covering the surface.

Mobility challenges occur when people stay in the same position for a period of time, either lying down or sitting in a wheel chair.  There is pressure created between the surface that they are lying on and the bone itself: hips, heels, back of shoulders, and elbows are all affected.  For example, there is tissue between the hip bone and the bed.  By lying in that position, it causes pressure and compresses the skin between the bone and surface that they’re lying on.  The skin is the largest organ in our body and it’s very vascular.  It needs blood supply to bring nutrients and oxygen to the skin and to remove waste products such as carbon dioxide and other matter.  At the level of the skin there are small blood vessels called capillaries which are susceptible to compression.

By having that compression, you decrease the blood flow to the skin so you lose the ability to bring nutrients and oxygen to the skin, and the ability for waste and carbon dioxide to be removed from the skin.  So you make the skin susceptible to injuries and not being able to repair that injury.

Another reason for bedsores is that as people get older they tend to lose more subcutaneous fat; the skin gets less elastic and that also creates an inability to repair itself.

Moisture can cause the skin to get boggy and create inelasticity as well.

Moisture can be created by edema in the skin, by fecal and urinary incontinence. This all creates an environment that is conducive to having pressure ulcers. Moisture increases skin breakdown.

Vitamin A, C and E deficiencies and low protein increase the risk of pressure ulcers.  All three of these vitamins are important for collagen synthesis and wound repair, all necessary in maintaining intact skin.

The mechanics behind it are friction, the pressure that I discussed and something called shearing.  Shearing is a combination of pressure and        friction.  When someone is lying on a surface, it can cause movement of one layer of skin against the other which can cause tearing.  The shear injury is not visible on the skin level but is the cause of much of the damage associated with ulcers.

Friction is when one surface moves against another surface, such as when a patient’s skin slides across a bed sheet.  The pressure that we’ve talked about is between the bone and tissue and it’s decreasing the capillary blood flow in order to bring nutrients and oxygen to the skin and to take the waste products out.

Friction is what happens when people are cleaning areas vigorously, moving against a surface (example, moving against a sheet or a cushion.  Some people are more susceptible to pressure ulcers because of loss of elasticity and subcutaneous fat—that force can cause injury to the underlying skin.

Issues surrounding shearing is similar to friction.  You have several layers of the skin and one surface of the skin rubs against the other.  Bedsores can become extremely severe.

The skin has three layers: the epidermis is the outermost part of the skin.

The dermis is beneath the epidermis which contains the connective tissue, hair follicles and sweat glands.

Below that is the hypodermis which contains the connective tissues.

Blood vessels go throughout the area providing the nutrients that I described earlier.

Pressure ulcers can develop within a two to six hour period.


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