When we are taken ill or have a condition that means long periods of rest we assume that sitting back and relaxing is just what the doctor ordered. Sadly, this isn’t necessarily the case. Long periods of inactivity can encourage pressure sores that can turn very serious, very quickly.
If you’ve never heard of a pressure sore or a pressure ulcer, it’s time you did. The development of pressure sores on the body is generally not down to anything simple like poor hygiene or in fact, anything complicated such as a specific virus or bug. Anyone can get them and although the problem is simple people are still suffering.
A pressure sore occurs when a patient has to take a period of rest and is unable (or unwilling) to move for quite a long period of time. The amount of time it takes for a pressure sore to develop is dependent on patient variables including age, weight, shape and physique but it can take as little as a couple of hours for the first signs to emerge on what was previously perfectly healthy skin.
Early intervention can eradicate problems before they become even a small inconvenience but if not treated a pressure sore can soon become a pressure ulcer which in turn can spiral out of control and in very severe cases contribute to fatal outcomes. The issue of skin health needs to be taken seriously.
Professor of Vascular Surgery at Freeman Hospital, Newcastle upon Tyne, Gerard Stansby, suggests that outcomes depend largely on patient variables, saying: “They depend on what part of the body, how extensive they are and what other conditions the patient has. In some cases they will heal quickly, in others they may need prolonged hospital stay and may even contribute to death”.
As with many medical issues, the status of pressure sores has been updated and upgraded. For years people have largely assumed that what they called ‘bedsores’ were simply an issue for patients that stayed in hospitals for long periods. The updating of ‘bedsores’ to ‘pressure sores’ now takes in the fact that such issues are familiar to wheelchair users and those that spend long periods being inactive.
A pressure sore is simply an area of damaged skin usually caused by lying or sitting in one position for too long. When the amount of force exerted on an area of skin is greater than the capillary pressure, blood flow becomes restricted leading to tissue and sometimes nerve damage. (The effect is rather like a sponge drained of water after squeezing – the water, or blood provides the oxygen to keep the tissue alive but is literally forced out under pressure.)
Even though the sores are largely similar there are three distinct types of causation:
This is literally the amount of force (weight) applied to the tissues between the bone and an object such as a support. In these cases patients with high risk are those who are not able to move in a bed or chair without assistance.
This is the result of two parallel surfaces moving in opposite directions to each other. This can occur when skin rubs against bedclothes or cushions, with the outer layers becoming damaged due to slow abrasion.
Similar to friction but specifically when underlying tissues become twisted or torn leading to restriction of blood vessels. The skin effectively starts to die.
Blisters caused by overusing tools or by trapping skin in a drawer say are painful for a moment but the patient is usually able to make quite a swift and painless recovery within a day or so. Pressure sores are not nearly as simple a problem as this. For one thing the causes are not acute, in other words pressure sores take far more time to develop. For instance, a patient may be propped up against pillows in a bed and may take 40 minutes to slide into an uncomfortable position. During this time their skin is not necessarily receiving optimal blood flow and is at risk from developing a sore through friction or shear pressure, particularly if they are simply shunted back into position for the slow sliding to begin again.
Patients may find that they acquire pressure sores in hospitals because of the amount of time they spend being inactive. Sadly, at the same time patients will have medical complaints that leave them tired and vulnerable to acquiring infections. A pressure sore that breaks the skin and becomes ulcerated can be bad news anyway but in these particular circumstances it can be dangerous.
Among worst case scenarios are that the ulcer becomes infected, leading to nerve damage, blood poisoning or if it gets deep enough, bone infections. Pressure sores can range from non-painful marking to deep ulcers that are painful, unpleasant and distressing.
The initial symptoms look incredibly harmless. Patients at risk in any environment, hospital or home, should certainly be on the lookout for changes in the appearance or feel of their skin. The usual first sign is a change in colour with areas of skin becoming either reddened or darker in tone with bluish/purple discolouration. Sometimes blisters will occur quickly.
Accompanying this may be symptoms that include one or more of the following: skin that is hotter or colder than usual, swelling and patches of hard skin. All of these symptoms are signals that all is not as it should be and should be afforded attention.
The most common areas where a patient is likely to experience pressure sores are boney extrusions, particularly at the heel and the sacrum (the small of the back). Clearly, being in a prone position means that weight is borne on these two thinly covered areas. Patients have even discovered the beginnings of sores after waking from surgery where they’ve been propped against a bed guard or the like. Naturally sedation means that for a time parts of an otherwise fidgeting body won’t move and sores can even develop where equipment like masks or catheters meet the skin.
As patients, we have a responsibility for our own care and to help medical staff make the best decisions for (and with) us. To this end, if you have concerns, you need to politely express them and try to offer a constructive contribution, such as requesting to be ‘moved’ in half hour intervals. Good practice amongst medical staff will include ‘moving’ patients at risk as well as inspecting their skin to make sure that any developments are acted on and monitored.
Part of the monitoring process should include an initial assessment and a form of action plan to prevent worsening (and new sores developing). To this end there are three essential stages in order of severity: intact, superficial and deep.
The skin has not yet ‘broken’ but shows distinct signs of damage including discolouration that does not disappear when gently pressed (as a rash might). Depending on the causation the skin can feel either hard or slightly ‘mushy’ – being filled with fluid.
Indicated by a partial loss of skin and presenting as a blister or shiny/dry shallow ulcer.
A deep pressure ulcer is where the skin is completely worn through and subcutaneous fat (may be visible). The wound may be smaller than the extent of the circumference of damaged tissue underneath the surface (sometimes referred to as undermining).
There is a fourth category beyond ‘deep’ that indicates the full extent of the severity of pressure ulceration. Not only will there be tissue loss but it will be to a depth where bone and tendon may be visible (and will include undermining).
Sometimes where skin tissue has died (known as necrotic tissue) the increase risk of bacterial infection is heightened and the removal of the dead tissue (debridement) has to be considered although this isn’t as grave as it sounds since it can actually hasten the recovery process. Furthermore it isn’t always necessary if the area is stable (for example if there is a fairly solid ‘scab’ or ‘eschar’ in place).
Pressure sores are not rare but they aren’t inevitable. New thinking points to improvements in prevention that mean that with appropriate care and attention the risks of acquiring pressure sores (at least in hospitals) are becoming lessened.
Professor Stansby points to a few simple reasons why patients continue to have problems, including a lack of assessment, failure to apply preventative measures, a failure to appreciate the problem and perhaps a focus on other things with solution being simply, “more education, training and resources”.
This appears to put the ball back into the patients’ court since any number of medical problems in our hospitals could be solved with increases in staff numbers and vigilance and yet there clearly isn’t the money available to spend on implementing such notions. It simply isn’t going to happen.
For the moment patients’ and their immediate carers will be the first line of warning and defence against pressure sore developments. There are definite do’s and don’ts and the NHS have come up with a simple pneumonic: S.S.K.I.N, that helps people remember the crucial observations they need to make:
Skin – Check skin regularly (at least once a day) for signs of damage.
Surface – Use specialist aids and cushions to help redistribute pressure (weight).
Keep moving – Change position regularly when sitting or in bed.
Incontinence – Try to keep skin clean and dry. (This also applies for people that sweat excessively.)
Nutrition and Hydration – Eat a healthy diet and aim to drink up to 8 glasses of fluid per day. (This can include caffeinated drinks but not alcohol.)
Again, the aim should be all about prevention. However, such things are unpredictable and so treatment options also need to be thought about. In a sense, a pressure sore is something of a ‘yellow card’ in itself and a time to make an attempt to keep the sore from turning into a full-blown ulcer. All of the steps discussed thus far would potentially help to achieve this.
If a pressure sore does occur, the primary concern should be to keep it as small (localized) as possible. Again, the first step of this management is an effective observation regime that monitors size, shape and skin condition on a regular basis. This should not end with the effected area but be the starting point of an extensive survey to make sure that other sores are not developing or that the ulcer itself is not gaining.
The treatment of an ulcer (and even a sore that gets to superficial stage) should be treated with guidance from a medical professional. Wound cleansing in this instance is not like wiping the grazed knee of a child with disinfectant. Medical professionals will have the knowledge and expertise to identify superfluous surface debris, bacteria and other contaminants and can advise on irrigation solutions where necessary.
In cavity wounds an element of exploration will be required. This should be undertaken by a medical technician/nurse or doctor to make certain that there are no pockets or undermining from the ulcer.
Medical professionals will also be able to advise on the correct use of barrier creams to reduce shear forces and minimize the risk of contamination by micro-organisms. Again, the other treatments involve keeping skin clean and dry where it can be soiled by incontinence and sweat.
The ‘How To Guide: Wound Essentials, Pressure Sore Management’ notes produced by Wounds UK also points out the importance of differentiating between a moisture lesion (related to incontinence and usually found in the peri-anal area) and pressure sores that are almost always located around boney prominences.
Much of the treatment follows a similar pattern to the preventative measures prescribed. As well as aiming to keep skin in good condition, the surface that the patient rests on should be designed to redistribute pressure and weight, especially away from an effected area.
The patient should be moved regularly and encouraged to be as mobile as they can reasonably manage. Any slight mobility will be a real benefit to the patient, as will a good diet and hydration. This is a factor towards general wellbeing.
Another part of pressure sore/ulcer management is to recognize that they are painful and distressing to the patient. It is a good idea to address pain relief, especially during changes in dressings and during movement.
In all cases, if there is a risk (or there are signs) of infection your healthcare professional may treat it with antibiotics or dressings that will specifically kill bacteria and help the wound to heal.
The guidelines produced by National Institute for Health and Clinical Excellence (NICE) explain that there are three modern recommended dressing types that may be suitable to apply to pressure sores:
These adhesive dressings are gels that cover the wound but do not stick to surrounding skin.
Another simple gel that keeps wounds moist and can help keep it clean.
Available in different shapes and sizes, foam pads are designed to absorb and retain fluid away from the surface of the skin.
The essential difference between these three dressing types and older, more traditional products is that they are far more sensitive to the surface of the wounds. Because of this they do not become ‘stuck’ fast or entangled in the wound and do not pose a risk of further encouraging bacterial infection.
Dermal pads can be lightly held in place by the patient’s own underwear. It is important that the area of skin underneath is monitored regularly (and carefully). The carer will usually have to help the patient to carry out such inspections. Cleansers with balanced pH values and barrier creams can be used to prevent further skin breakdown through the effects of incontinence and can be used at the same time as urinary and faecal management systems.
For full thickness (deep) pressure damage, consider using an anatomically shaped sacral wound dressing or soft silicone border dressing for fragile skin at risk of becoming ulcerated.
Dermal pads can also be used on heels but should not be applied so as to reduce mobility. They are usually held in place by a bandage or sock. Again a silicone border may help reduce the chances of the problem spreading although if the heel has a stable ‘scab’ on it, there is an argument for leaving it alone – apart from the regular inspections.
General advice is to take weight/pressure off the heels.
The products used by medical practitioners and domestic carers alike have developed considerably over the years. With an ageing population, more of us can be expected to have to visit hospitals where much of the observations and experiences underlying our knowledge of pressure sores are obtained.
The preferred filling material for many of the weight redistribution products such as cushions and pads is medical grade silicone. Tests conducted by Trulife (a leading medical device manufacturer specialising in pressure sore management) concluded that silicone is far more effective than polyurethane gels at differing thicknesses and applications. Trulife told Able about statistics that show people can suffer a pressure sore in surgeries that take just 3-4 hours adding, “Our pads essentially help redistribute pressure from high pressure areas. Silicone gel helps prevent shear and friction. It is essentially compatible to human skin, and durable”.
Further to these variations in medical environments mean that the materials in use have to withstand all manner of challenges regarding safety and non-interference with other procedures and treatments. For the most part then, silicone is the chosen material because it is safe in terms of not supporting microbiological growth, people are not likely to be allergic to it as they are with say latex or fibreglass products and it gives outstanding mechanical resistance whilst being softer than skin and underlying tissue. (This is important because the lack of ‘give’ in other products means that skin again starts to deteriorate when pressed against the harder surface.
Other issues include temperature testing; important because overheating in response to human contact will lead to perspiration problems. Silicone is also non conductive (of electricity) and does not interfere with imaging by x-ray or MRI machines.
Most of all, the silicone gel performs most like human skin and supports weight without bottoming out. If it did ‘bottom out’ and was squeezed out from under the body part it supports it would actually increase the problems associated with pressure sores since more of the skin surface would be under pressure contact with the device surface.
Good quality products and good quality care very often go together with Trulife explaining how they feed their expertise into hospital units saying: “Our distributors visit hospitals and go to exhibitions to educate the operating staff more and more about pressure sores and the options available to assist in the prevention”.
Despite new innovation and a more positive approach in the prevention and treatment of pressure sores, the unavoidable issue is that care givers are the key to eradicating the problem. As well as becoming an older population, we are also becoming bigger (or fatter or more frequently obese). In other words, the weight of the average patient has gone up. This means that the equipment used to treat ‘average’ patients only 10 years ago is now unsuitably small in relation to ‘average’ requirements concerning size, shape and weight.
The increased size of patients goes hand-in-hand with some of the symptoms of patients at greatest risk of developing pressure sores, including higher perspiration levels and most acutely more weight for the skeleton to support in a prone position, leading inevitably to shear, friction and pressure. President of High Country Medical, Clare Williams Tager, says in her white paper on ‘Patient positioning” that: “Consequently we can no longer safely use equipment and padding that was the standard 10 years ago. For 300lb patients, we cannot place them on a 2” foam mattress and expect to have no pressure problems.”
Tager goes on to suggest that such is the importance of avoiding pressure sores that surgical teams need to spend quality thinking time finding ways to keep their patients safe saying: “Safe positioning requires that the surgical team compromise, collaborate, discuss, and if necessary take a time out.”
Another voice on the subject, Dr Lena Gunningberg (in her paper: “Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action” published by the Journal of Evaluation in Clinical Practice) cuts even quicker to the ‘chase’ by suggesting that all strata of medical staff need training in this area, saying: “Nurses compromise the largest group of professionals employed in hospitals, and are thus uniquely positioned to significantly influence patient safety and quality of care.”
Not common knowledge
In this sense Gunningberg really puts a different spin on the entire issue. No longer is it a purely clinical issue, it’s a health and safety issue. The fallout from this viewpoint can be seen as meaning that pressure sores can no longer be blamed on happenstance: they are the product of bad practice and at worst neglect on the part of medical professionals all the way up the ladder.
This new viewpoint, of an ‘unacceptable’ labelling of pressure sores means that hospitals might well be at further risk of becoming targeted with negligence and malpractice suits. In fact, perhaps part of the reason why more patients and carers don’t know about the potential dangers of pressure sores is because as Tager puts it: “Once a settlement is reached regarding a hospital-acquired injury the patient invariably signs an agreement that no publicity about the case will be allowed” adding that: “This cloak of silence damages the potential for real change to be instituted to prevent these injuries or to reveal how much more it costs to treat them than prevent them.”
With this point in mind Professor Stansby tells me about the work that NICE are carrying out to make sure that patients know enough about their treatments to be able to make informed choices saying: “Nice also prioritise informing patients and carers of the key facts so they can become informed.”
For the time-being, the best thing that a patient or carer can do regarding the issue of pressure sores is to have an awareness of them. Self education is crucially important for not only those at home but also for those treated in hospital. There is certainly a place for engaging medical staff and encouraging a regular inspection and changing position regimen. Pressure sores can delay recovery from other illnesses and can become a significant issue in their own right. They are well worth taking steps to avoid.
There are any number of preventative measures that can be applied as well as appropriate products for the different sorts of pressure sores. As Professor Stansby concludes: “The vast majority of pressure ulcers are avoidable. Care may be poor in the sense that the risk isn’t recognized early, preventative measures are not used and then pressure ulcers can form very rapidly – within a few hours in some cases.” Pressure sores then, are not insignificant despite their small beginnings and they are certainly not inevitable.