Dr. Kumkum J. Khadalia. Plastic Surgeon.
What is a pressure sore?
"A pressure sore (bedsore, decubitus ulcer) is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually located over bony prominences." Pressure sores are preventable.
Two mechanical forces contribute
• Prolonged direct downward pressure between a bony prominence and the seat or bed can prevent blood from reaching the compressed tissue. Pressure is transmitted in a cone shape with the point of the cone at the skin surface and the base overlying the bone. If the pressure is removed allowing blood to circulate, the initial damage may be reversed. Generally speaking, irreversible damage can occur if pressure is not removed for more than 2 hours.
• Shear / friction pressure.
Classification of pressure sores
Depending on the amount and duration of the pressure and other extrinsic and intrinsic predisposing factors, the sore that results may belong to any of the 5 different stages.
Stage 1: Mild redness or duskiness of the site -- On applying and releasing finger pressure the redness disappears and then reappears. This stage is reversible and for the affected area to recover it needs relief from pressure for half the time that it was under pressure.
Stage 2: Redness, which does not disappear with finger pressure. This results in superficial ulceration exposing dermis.
Stage 3: The subcutaneous fat is exposed.
Stage 4: Muscles are exposed.
Stage 5: The damage extends up-to bone or underlying joints. In this stage the skin wound is only the tip of the iceberg with 70% of the ulcer lying below the skin. Deep pressure sores can take as long as a week to manifest.
Who gets pressure sores?
Individuals who have impaired mobility and stay in one position for a long time. Paralyzed, debilitated or comatose persons confined to bed (and wheelchair) are more likely to get pressure sores. However, even people who are able to walk can get pressure sores on their feet if they have no sensation on their feet.
Where on the body do pressure sores develop?
Pressure sores usually develop over bony prominences where there is less padding.
How does one recognize a pressure sore?
• Mild damage causes skin discolouration, but a sore doesn't form. In light-skinned people, the skin may turn a dark purple or red. In dark-skinned people, the area may become darker than normal. The area of damaged skin may also feel warmer than the surrounding.
• The skin may become black and dry and hard. This is called an eschar.
• There may be ulceration or sore formation; surrounding warmth, tenderness, and swelling; drainage of yellow or green fluid from the ulcer base indicating secondary bacterial growth; pain in the area if sensations are not lost.
• Other signs are: an increase in spasms, unusual sweating, and fever.
How to prevent pressure sores
1) A person who is confined to a bed or chair should change position at least every 2 hours during the waking hours and every 3 hours during sleep with the use of an alarm clock. In certain cases more frequent position changes may be indicated.
2) If for other medical reasons, the position cannot be changed, then the patient must be lifted clear of the supporting surface for a second after every 30 minutes or else he must be provided with a pressure distributing bed.
3) Precautions while sitting:
a) When sitting in a chair or wheelchair, sit upright and straight. Do not allow yourself to slide forward. Perform regular pressure relief, such as "push-ups" from the wheelchair (keeping the wheels in the locked position) and shift your weight. Some medical experts recommend weight shifting or elevating for one minute every 15 minutes. Spread your weight over a larger area by resting your elbows on the armrests of the wheelchair to take pressure off your bottom. If you cannot move by yourself, have your caregiver shift your position at least every hour, more often if possible.
b) The size and fit of a chair or wheelchair are as important as any pressure-distributing cushion.
c) Wear shoes when in your wheelchair.
d) It is important to provide aids that the patient can hold on to, or push against, to prevent sliding - e.g. padded foot boards, side-rails, or an overhead `trapeze'.
4) Take special care to keep bony prominences from direct contact with one another. Specially designed cushions can be used to redistribute weight to prevent sores from developing. Don't use doughnut or ring-shaped cushions, as this would result in compression of the skin surrounding the ulcer congestion of the area enclosed decreased tissue oxygenation worsening of the ulcer. Do not use folded blankets or towels as these can be quite firm.
5) Avoid direct pressure on the heels and do not allow the weight of the covering sheet or blanket to fall on the toes by using a foot cradle.
6) Skin care is essential. Keep the skin healthy by keeping it clean, dry, and lubricated. Very dry skin should be treated with moisturizing cream or lotion. Dry skin and oedematous tissues are particularly vulnerable. The patient and family should be advised to:
a) Use a mild soap and wash the skin only once or twice a day, unless there has been incontinence or excessive sweating. Rinse with water to remove all the soap and dry by patting and not by rubbing.
b) Avoid frequent use of chemicals as these rid the skin of surface fats and make the skin more vulnerable.
c) Barrier agents may be useful if there is incontinence or if frequent washing is required.
7) Where there is urinary or faecal incontinence, skin-care measures are even more important.
8) Regular inspection is vital and should be the job of all team members. Do skin checks before dressing in the morning and the last thing at night before going to bed. Pay special attention to the pressure points where sores are most likely to occur. Look for spots, colour changes such as redness or dark areas, cracks, bruises, and blisters. Use a mirror for places you can't see. Long handled, flexible mirrors will help in this task. Feel for lumps, soft areas or unusual warmth (use the back of the hand).
9) Make sure that the bed sheets are smooth and not wrinkled. Use porous, absorbent material, it will allow air circulation and prevent moisture build-up.
10) Use a proper foam mattress at least 7” thick and the foam should not be fatigued. The body should not sink through the thickness of the mattress to rest on the firm bed. Protective films, dressings, creams, and padding may be used to minimize friction and shearing.
11) Prevent the hammock effect. The supporting medium should mould around the body. So there must be an appropriate cushion on the wheel chair. The sheet covering the bed mattress should not be tucked in too tight under the mattress during bed-making
12) Good nutrition is important because it helps prevent the occurrence of pressure sores and also helps your body heal the sore. If you do not get enough calories, protein and other nutrients, your body won't be able to heal, no matter how carefully the pressure sore is cared for. Nutritional evaluation for recommendation of protein supplements, vitamins, minerals, and other nutritional needs is essential. Be sure to tell your doctor if you have lost or gained weight recently. Some studies show zinc and Vitamin C help promote healing of large wounds.
13) Maintain level of physical activity. Exercise can help maintain blood flow. If the bedridden person is not capable of exercising, others can administer passive movement or exercise. Avoid getting cuts and bumps.
14) Wear clothing without thick seams, multiple pleats and other causes of pressure such as snaps, buttons or studs. Also avoid tight, constricting garments or elastic bands as well as loose garments that can fold and wrinkle.
15) Never put a heating pad where you have no sensation.
16) Don’t store objects under your chair cushion. Use a bag or backpack on the rear of the wheelchair.
17) Regularly check your wheelchair cushion and your mattress for fatigue.
18) If you detect redness, irritation or abrasion, you should suspect excess pressure in that area. Check your wheelchair cushion, bed mattress, bed-sheets, shoes, clothing, etc. and try to determine whether there is equipment breakdown or whether you need to shift weight, do wheelchair push-ups, or practice other pressure-relief techniques.
19) The indications for a special support surface
a) Where repeated lifting cannot be readily accomplished.
b) If a person is not able to move him/ herself and if turning and repositioning him every two hours is not enough to prevent the development of a pressure ulcer.
c) If movement is not allowed for medical reasons.
When to call your doctor
When you first detect a pressure sore at any stage.
If an existent ulcer becomes infected.
How are pressure sores treated?
Relieving the pressure that caused the sore
Treating the sore itself
Improving nutrition and other conditions to help the sore heal
Studies show smoking works against the healing process.
If a sore develops, what can be done to eliminate the cause?
Try to determine what caused the pressure sore. What position have you been in to allow a sore to develop there?
After determining the answers to the questions outlined above, you or an assisting examiner should place a hand between the red spot or pressure sore and the wheelchair seat or bed mattress and try to measure whether there is excess pressure present. lf pressure doesn't seem excessive, you should suspect another cause.
Another cause could be the equipment you're using, such as wheelchair cushion, bed mattress, shoes, or whatever. A deep pressure sore can take as long as a week to manifest, so look beyond the last 24 hours.
You should ask:
• Has there been a change in the equipment recently, such as air leakage or wear out?
• Have you changed your activities recently?
• Have you been sitting more than usual?
• Have you taken a long trip?
• Have you been careless in weight relief or turning routine?
• Have you been ill or had fever recently (fever requires more frequent pressure relief)?
• Have you had a fall or did you develop an abrasion while transferring?
If you find what you believe to be the cause of the sore, take corrective measures.
If there is no improvement after a week, then look for another cause.
If there is no improvement in the situation, you will need to go see your doctor.
How do I know if the wound I'm treating is infected?
Signs of an infected pressure sore include the following:
Swelling around the sore
Redness or warmth around the sore
Tenderness around the sore
Thick yellow or green pus Bad smell from the sore Bone exposed
Signs that the infection may have spread include the following:
Fever or chills
Mental confusion / difficulty concentrating
Laboratory tests to determine whether an infectious process is occurring include:
White blood cell count (WBC), Wound swab culture, Blood culture.
The pressure sore dressing
To heal, pressure sores must be kept clean, free of dead tissue and also free from pressure. Antibiotics (oral or topical) may be prescribed Hand washing, clean dressing supplies and new gloves are required. Proper disposal of contaminated waste is a must. Also, protect the wound from urine or fecal contamination.
Do not use topical agents such as: povidone iodine, EUSOL, hydrogen peroxide,acetic acid.These are harmful to cells, and can inhibit the normal healing process of a sore especially if used in the wrong concentration and recurrently.
There is a myriad of dressing materials available today. The choice of the dressing depends on the appearance and behaviour of the sore, thus it may need to be varied each time the dressing is done. There is no one dressing that can be prescribed for all wounds. The person who does the dressing needs to be able to decide
• what would be suitable and
• to change it if he does not get the expected response or
• change it if the end result of that particular dressing is reached e.g. certain applications help to get rid of dead tissue, so when all the dead tissue is out, there is no further need for that application.
The principles involved in the selection of a dressing:
· Healing is better in a moist environment. However certain bacteria thrive in a moist environment and are unable to thrive in the dry environment.
· There is a mixed flora contaminating/ infecting the wound so one can use:-
• antibacterial –
Ø glycerine acriflavin,
Ø silversulphadiazine [avoid in case of sulfa allergy]
Ø Nadifloxacin cream,
Ø Feracrylum lotion / gel
Ø neosporin powder/ ointment (do not use more than one tube or bottle of Neosporin in a month);
• anti-anaerobes – metronidazole gel;
• anti-fungal – clotrimazole powder;
· Aloe Vera gel or lotion – for its anti-inflammatory, antibacterial and anti-fungal actions.
· There is a vast array of local applications. So long as the application does no harm in terms of delaying the healing process or causing some harmful effects on the rest of the body, it may be used. The dictum is
· “Apply any application on the pressure sore but do not apply the patients weight”.
· Dead tissue (which may look like a scab, or yellow or white areas) must be removed from the pressure sore by one of the following means:
• Rinsing the sore every time you change the bandage is helpful.
• Chemicals that help dissolve the dead tissue eg Collagenase- Cream
• Apply wet gauze on the sore and allow it to dry. The dead tissue sticks to the gauze and is removed when the gauze is pulled off.
• Surgical removal.
• Maggots that selectively devour only the dead tissue.
· Wound discharge should not be allowed to macerate the surrounding skin
• barrier creams e.g. zinc oxide paste.
• An absorbent pad such as sanitary napkins can help keep the area relatively dry.
Once the bed of the wound is red non-adhering tulle should be applied as the first layer and then saline soaked and squeezed gauze.
If normal skin needs to be cleaned at least once a day, a wound must definitely be cleaned daily and if necessary, more than once a day. The dressing must be changed as often as necessary depending on soakage by the wound discharge or soilage by stools or urine.
If the person is able to take a bath, and if there is no particular contraindication, the wound dressing must be removed before or during the course of the bath and the wound must also be washed with soap and water. The dressing should then be applied after the bath. If bathing is not possible then cleaning the sore usually involves rinsing the area with salt-water solution. The salt water removes extra fluid and loose material.
Minimum adhesive tape should be used (micropore tape) to hold the dressing in place.
Wound care advice
1. Clean the wound with either saline or bathing soap and tap water during a bath for 5 minutes and rinse away all the soap leaving no residue.
2. Occasionally apply a moisturizer / coconut oil / liquid paraffin to the skin surrounding the sore as this skin gets depleted of its’ natural oil due to frequent cleansing.
3. Measure the wound, stage the wound, assess granular (red) and necrotic (yellow) tissue.
4. Apply an anti-bacterial or antifungal. For stage 2 sores use hydrocolloid sheet.
5. Zinc oxide paste on surrounding skin if significant wound discharge wetting the area.
6. Cover with sanitary pad if drainage is moderate to heavy or gauze pieces.
7. Secure dressing with Micropore tape or where possible, with a binder as the repeated removal of tape can cause blistering and pealing away of the outer layer on the skin.
8. Change dressing definitely once a day and more often if the dressing is saturated or leaking or soiled with urine or stools.
9. Monitor for signs and symptoms of infection.
10. Keep pressure off the wound.
11. Generally speaking, if the area is too wet, use a powder and if it is too dry, use a cream.
12. Call the doctor if wound deteriorates or on a regular basis to report progress.
How can I tell if the sore is getting better?
It may take 2 to 4 weeks of treatment before you see these signs of healing:
• it will slowly get smaller
• less fluid will drain from it.
• new, healthy tissue (light red or pink and looks lumpy and shiny) starts growing at the bottom of the sore.
When may surgery be needed?
• Exposed bone. Such wounds usually won't heal unless there is a soft tissue cover.
• Bad location. If the sore is in a spot where daily activity will aggravate it, for example a sore over the ischial tuberosity (sitting bones).
• Wounds that won't heal even though they may not look unusually bad.
• Drainage tracts with a small opening.
• An adherent scar following the healing of a pressure sore, which breaks down repeatedly under pressure.
Types of surgery
• Skin grafting
• Excision and suturing
• Excision of the sore and local flap
• Flaps designed to bring skin that has sensation to the area of the sore in appropriate cases.
• In some cases of multiple, stage 5 sores around the hip, amputation of the lower limb utilizing the skin of the limb to cover the sores.