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To begin with, pressure ulcers (PUs) remain a serious problem in nursing. It is the most typical and common condition among the hospitalized or bedridden individuals, which needs to be prevented. Decubitus ulcers cause pain, disfigurement, and increased infection risk for blood and bones.
This paper deals with the general information on PUs ulcers, defines the notion of a pressure ulcer, points out the areas of its localization, identifies its stages and their characteristics according to the international classification, distinguishes its signs and symptoms, describes its triggers and causes, as well as indicates the preventive measures, guidelines for its assessment and treatment.
The location of PUs depends on various postures and positions of a patient. PUs, generally, occur in the parts of the body where bones are close to the skin, and skin feels pressure against chairs or sheets with mattresses. When a patient is constantly sitting: coccyx, ischium, backs of heels, elbows, and shoulder blades are at risk. A person lying on the back may have PUs on the back of the head, shoulder blades, elbows, coccyx, and heels. An inspection of the individual lying on the side may reveal PUs on an ear, side of the shoulder, pelvis, hip, knee, and ankle.
Risk Factors for PUs
Risk factors for decubitus ulcers are defined by age, decreased mobility, exposure to skin irritants, and impaired capacity for wound healing. Bedsores mainly affect elderly people (possibly because of reduced subcutaneous fat and capillary blood flow), the disabled with limited ability to change his/her position, and individuals with prolonged stay in bed or confined to a wheelchair (McIntyre et al., 2012). The nursing home residents are at the highest risk of developing pressure sores.
Diseases that decrease blood flow to the skin (arteriosclerosis) or lessen the sensation in the skin (paralysis, neuropathy) intensify the development of PUs. Individuals with frequently moist skin due to perspiration or loss of bladder control are inclined to develop PUs. Such medical conditions as diabetes, venous and arterial insufficiency, Alzheimer's disease, malnutrition (esp. proteins), as well as malnourishment strengthen PUs and obstruct the healing processes. Inadequate nutrition may be a reversible risk factor for pressure ulcers. The individuals at risk of PU development should be treated with special caution.
Causes of PUs
Decubitus ulcers develop as the result of several causes. Pressure, friction, shear, and moisture are the main factors negatively affecting the formation of PUs (McIntyre et al., 2012). Out of these factors, prolonged pressure is the main factor causing bedsores. Application of pressure to the soft tissue of the body obstructs blood flow with oxygen and nutrients to it.
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As a result, the skin gets damaged with an appearance of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces. Friction is dangerous for blood vessels under the skin because two surfaces are being rubbed against each other. In addition, when poor lifting and moving techniques are applied, the top layer of the skin can be removed through friction with a bed or chair surface.
Repeated friction is a major cause of PUs. In such cases, ulcers are typically located on elbows or back during moving or transferring an individual with impaired mobility. What is more, the other cause of PUs is shear that separates the skin from the underlying tissue. Shear pulls on blood vessels that feed the skin. It may occur while moving an individual whose skin is stuck to the sheet or sliding down while sitting in a chair. Skin wetness due to sweating or incontinence also reinforces the appearance of PUs. The cause of bedsore affects the PU management strategy.
Signs and Symptoms
The appearance and development of PU take some time and evoke a dangerous and painful process in the affected area. The formation of PU starts with a painful red area appearing on the skin, which gets worse over time, forming a blister and, then, a sore. Minor redness on the skin and later a red painful area hide severe damage under its surface associated with an inadequate blood supply to the underlying tissue. Shortage of blood supply (i.e. deprivation of oxygen and nutrients) leads to tissue damage and cell death. If the pressure is too high, a cell membrane of muscle cells becomes damaged, then the muscle cells die.
Skin, nourishing through blood vessels thanks to muscles, stops. A deep tissue injury with necrosis forms and the skin becomes purple. Then skin external processes become deep and severe. In extreme cases sores spread deeply under the skin, destroying underlying muscle and bone. PUs are dangerous when a biofilm occurs in the wound and inflames it. The area around the ulcer changes its appearance and microclimate in comparison with the nearby tissue. Symptoms and signs of PU depend on its stage.
International Classification of PUs
Depending on the depth and severity decubitus ulcers are grouped into four stages by the NPUAP/EPUAP/PPPIA.
Bedsores, like any other medical condition or disorder, are easier to prevent than treat. Preventive measures include redistribution of pressure, minimizing pressure, elimination of friction and shear, support surfaces, repositioning of an individual in a wheelchair or in bed without stress to vulnerable areas, moisture management, good care of skin, maintaining adequate nutrition and hydration, education of patients and caregivers (NPUAP/EPUAP (2014).
Frequent changing of the individual's position is a key strategy in PUs prevention. McIntyre et al. (2012) recommend that a patient in a wheelchair should shift his/her weight every 15 minutes, or be repositioned once an hour, lift himself if the strength of the upper body allows, lean forward and to the sides. Special programs with a time frame for turning and repositioning a patient for pressure reduction are applied to nursing home residents. A bedridden patient should change his/her position every two hours.
Support surfaces that immerse and envelope the body into the surface are necessary preventive measures in PUs prophylaxis. Pressure redistributive mattresses and cushions play a significant role in reducing the pressure. Bedridden individuals should prefer foam-, gel- or air-filled mattresses, and use wetness absorbing pads, soft pillows depending on body position. Cushions can be very helpful in protecting bony areas. A frequency of turning and support surfaces are explicitly interconnected with the prevention of PUs.
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Skin microclimate management is an inseparable part of preventive skincare and PUs control. Heat and moisture levels on the skin surface of a patient should be controlled regularly (McIntyre et al., 2012). Gentle skin treating should be applied with a proper dry/moist regimen without hard scrubbing, talc powder, or strong soaps. Thus, a gentle cleaning, thorough protection, and daily inspection of vulnerable areas on the skin are paramount in PUs prevention treatment.
Moreover, individuals at risk of PUs should intake enough calories and proteins. A high intake of vitamin C and a healthy diet reduces the risk of PUs (NPUAP/EPUAP, 2014). Patients should drink plenty of water every day. The caregivers of individuals confined to a bed or wheelchair should be aware of proper patient transferring and moving techniques, effective PUs management, and treatment procedures.
Treatment of a PU
Treatment of a PU depends on its stage. The NPUAP/EPUAP (2014) clinical guidelines and recommendations on treatment strategies involve pressure redistributing support services, maintaining adequate nutrition, repositioning techniques, biophysical means, and wound care. Wound care begins with cleansing: a first step in preparing a PU wound for healing. Surface debris and dressing remnants are removed during cleansing a sore with potable water or normal saline, aseptic technique if applicable, or special cleansing solutions with surfactants and antimicrobials.
Pressure ulcers with undermining and tunneling should be cleansed with caution and avoid any contamination. If possible, a devitalized tissue should be removed in most PUs using the appropriate type of debridement, because it obstructs bacterial growth and inflammation. Depending on the condition of PUs, different materials for wound dressing can be applied. A thorough assessment of PUs helps to decide with a PU's stage, as well as identify the most appropriate management plan and treatment procedures.
To sum it all up, a pressure ulcer is a widespread medical problem directly associated with pain, disfigurement, an increased level of morbidity, sepsis, mortality, and extended length of hospitalization. A PU is caused mainly by pressure, friction, shear, and reinforced by age, moisture, malnutrition, and accompanying diseases that impair healing processes. The PU management strategy depends on its stage defined by NPUAP/EPUAP international classification. The caregivers of individuals who are at risk of developing bedsores should be aware of preventive measures because the statement prevention is better than cure is definitely a hallmark of pressure ulcers.