Pressure ulcers are skin wounds due to prolonged immobilization, whether sitting or lying down. They appear on pressure areas such as the buttocks or heels.
What are the symptoms? Can they be prevented? How to treat them? Here are our explanations.
A pressure ulcer: definition
A pressure ulcer is a localized area of ischemia, i.e. lacking oxygen, causing the suffering of the skin and subcutaneous tissues, caused by:
- pressure;
- shear;
- rubbing of the skin.
It begins with redness that does not fade when pressed on the skin and evolves into a wound that can go all the way to the bone.
The different stages of pressure ulcers
There are four stages in the evolution of pressure ulcers.
Stage 1 pressure ulcers
It is a redness that does not whiten with pressure, on a constant support area such as the buttocks or heels. From this stage, there may be a destruction of subcutaneous tissues, especially muscles, much more sensitive to hypoxia, that is to say, a reduction in oxygen, than the skin.
Stage 2 pressure ulcers
The superficial wound of the skin type of abrasion or simple bubble.
Stage 3 pressure ulcers
A deep wound of the skin affecting the epidermis, dermis, and subcutaneous tissues but not affecting the underlying muscles.
Stage 4 pressure ulcers
Wound up to the muscle or even the bone.
Who is most at risk of developing pressure ulcers?
People at risk are immobilized or bedridden people such as:
- patients who are hospitalized and bedridden for prolonged periods of time;
- paraplegic patients in wheelchairs;
What are the symptoms of pressure ulcers?
How to recognize the appearance of a pressure ulcer?
The appearance of a pressure ulcer is characterized by a simple persistent redness of the skin that does not fade when pressed. This is stage 1 of the pressure ulcer.
What are the causes of pressure ulcers?
Pressure ulcers are related to:
- constant pressure;
- shear;
- chronic skin rubbing.
This causes a decrease in vascularization or ischemia and therefore oxygenation of the tissues.
Muscles are more susceptible to ischemia than skin. A beginner pressure ulcer without a skin wound may therefore already have underlying muscle damage.
How is pressure ulcer diagnosed?
The diagnosis of pressure ulcers is made during regular observation of the skin by the healthcare team, especially with regard to bone prominences, by the discovery of a simple persistent redness of the skin that does not fade when pressed. This then corresponds to stage 1 of the pressure ulcer.
Unfortunately, sometimes the diagnosis is later, especially in people in wheelchairs who have lost all sensitivity, such as paraplegic people, by the discovery of a wound formed on a “hidden” area such as:
- lower back;
- buttocks;
Evolution and possible complications of pressure ulcers
Even a stage 1 pressure ulcer may have underlying muscle damage. They should therefore never be neglected. They are likely to progress to the following stages fairly quickly in the absence of adequate treatment.
The main complications of pressure ulcers are:
- pain in people who still have skin sensitivity;
- superinfection of the wound and underlying noble tissues, such as osteitis;
- the absence of healing despite a well-conducted treatment.
What are the risk factors for pressure ulcers?
Risk factors for pressure ulcers are:
- immobilization of a patient in a wheelchair or in bed, causing constant pressure on the skin, even skin shearing and/or chronic friction on areas of bone prominence such as the sacrum, buttocks, hips, ankles, elbows, the posterior part of the skull in contact with the bed, etc.;
- the absence of equipment limiting the risk of bedsores such as a bed or an anti-bedsore chair, cushions limiting prolonged support or foam wedges avoiding direct contact of bony prominences between them, such as knees, heels or ankles, etc.;
- the absence of a change in a patient’s regular position if his state of health allows it;
- the absence or decrease of a patient’s sensitivity to pain;
- the lack of correct positioning and transfer techniques for an immobilized patient, with the aim of limiting friction and shearing of the skin;
- areas of excessive moisture related to incontinence, sweating, or wound exudates;
- undernutrition or cachectic condition;
- the lack of physiotherapy and rehabilitation for a resumption of autonomy and walking, when the patient’s state of health improves.
How to prevent the appearance of a pressure ulcer?
To prevent and limit the risk of pressure ulcers, the 2001 French consensus conference1on pressure ulcer prevention provides the main acts to be performed by the healthcare team:
- identify “at risk” patients requiring individual prevention and the specific factors exposing them to this risk according to a risk scale;
- inspect the condition of the skin daily at the level of bone prominences according to the position of the patient such as the sacrum, heels, trochanter, malleoli, elbows, occiput, etc.;
- Avoid massages on bone prominences, as they do not prevent pressure ulcers and can, on the contrary, lead to additional tissue damage. Touch the sacrum with a peroxidized oil: Sanyrene®;
- assign to patients, at risk of developing bedsores, a bed and an adapted chair with the support that reduces support such as a mattress with mattress topper and cushion;
- use foam cushions or wedges, to avoid direct contact of bony prominences with each other (for example knees, heels, or ankles);
- change the patient’s position regularly, if his state of health allows it;
- minimize skin aggression related to friction and shear forces by correct positioning, transfer, and repositioning techniques;
- find and eliminate sources of excessive moisture related to incontinence, sweating, or wound exudates, if possible;
- plan nutritional intake and supplementation, after evaluation, in malnourished patients;
- begin rehabilitation for a resumption of autonomy and walking, when the patient’s state of health improves;
- Encourage patients to change their positions themselves if they can.
How to treat a pressure ulcer?
The treatment of pressure ulcers involves first of all compliance with measures to prevent its aggravation and the prevention of other bedsores: a patient with a pressure ulcer is at risk of making others!
Avoid further pressure ulcers and worsening of pressure ulcers
It is necessary to change the position of the patient with a pressure ulcer every 2 to 4 hours to modify the points of support. This is done by means of lifting devices, or when possible with the active participation of the patient by hanging from a stem located above the bed, or finally, by several people.
If possible, avoid placing the patient on his pressure ulcer. If possible, we use:
- cushions;
- foam wedges limiting supports;
- An anti-bedsore foam mattress or a forced air or water mattress: in this case, the patient rests on a canvas stretched under a flow of forced air or on a bag filled with water.
Pressure ulcers and physiotherapy
Daily physiotherapy is required in patients with pressure ulcers, allowing:
- mobilization in bed;
- the fight against muscle retractions;
- If possible, get him up, put him in a chair, and resume walking whenever possible.
In case of malnutrition hindering healing, doctors can resort to protein-rich nutrition solutions, Cetornan® type.
Wound treatment
Wound cleaning is done:
- tap water: if possible, the wound can be showered to remove debris;
- or with saline.
Antiseptics are only used in case of superinfection, for short periods, until the wound is clean and the skin around the pressure ulcer is less inflammatory.
It is necessary to remove all dead tissue – black, greenish, yellow – from the wound either:
- through wet dressings;
- by cutting the patient’s bed a nurse;
- or even in the operating room by a surgeon for large bedsores.
Once the pressure ulcer is clean and free of dead tissue, dressings are applied to help it heal.
New treatments, most often reserved for specialized teams, sometimes allow a valuable aid to heal. These are mainly:
- VAC therapy: application of constant negative pressure on the wound;
- hyperbaric oxygen therapy.
It is sometimes necessary to perform a skin graft or closure of the pressure ulcer by a surgeon in case of pressure ulcers are too wide.
The treatment of pressure ulcers must be carried out by a specialized team, most often the hospital.
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