How Pressure Ulcers Begin

How Pressure Ulcers Begin

Scope of the Problem

Pressure ulcers are a major concern in health care, today.   Pressure ulcers are defined as localized injury to the skin/ and or underlying tissues, usually over a bony prominence, as a result of pressure alone or in combination with shear (SITE PAPER 1).  The number of patients with pressure ulcers are increasing significantly.  It is estimated that up to 3 million adults in United Stated are affected by pressure ulcers (SITE PAPER 1).  Pressure Ulcers may become life threatening if left untreated.  A scale is used to properly diagnose the severity of each pressure ulcer. Previously, pressure ulcers were classified as stage I through stage IV or as unstageable (SITE PAPER 2).  A new classification called deep tissue injury is described as a bluish or purplish discoloration over an area of pressure or shear, which may be difficult to discern in patients with dark skin (SITE PAPER 2).  Everyone is susceptible to a potential pressure ulcer developing.  Other studies of risk factors have examined co morbid conditions, such as diabetes and peripheral vascular disease score on the Acute Physiology and Chronic Health Evaluation, ICU length of stay, presence of mechanical ventilation, use of sedatives, and the use of instruments to measure the pressure at the interface between bed and patient (SITE PAPER 2).  According to (SITE BOOK PG 190), increased risk for skin breakdown and the development of pressure ulcers are related to changes in aging skin and to situations that occur in the acute care setting, such as mobility, incontinence, and malnutrition. It’s important to educate healthcare providers and the community on pressure ulcers prevention and how to properly treat them.

Applicable Evidence

The most common area for pressure ulcers include the sacrum, coccyx, heels, and ear (SITE PAPER 2). These areas are more susceptible to developing pressure ulcers due the amount of moisture and constant pressure being applied. The epidermal layer may become emaciated, which will eventually turn into an ulcer. The pressure compresses small vessels and prevents both supply of oxygen and nutrient at the capillary interface as well as venous return of metabolic waste (SITE PAPER 2).  Metabolic wastes accumulate and cause local vasodilatation, which contributes to edema, further compresses small vessels, and increase edema and ischemia (SITE PAPER 2).  In addition, nutrition and aging increases the chance of developing a pressure ulcer.  As people age, subcutaneous fat decreases, which causes a thin dermal layer. Poor nutritional status causes a decrease in protein and renders tissues more susceptible to the effects of pressure (PAPER 2).

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In addition, pressure ulcers can occur from the hospital’s provided equipment.  Intensive Care Unit patients are more susceptible to develop pressure ulcers due to prolong bed use and continuous use of attached equipment. Equipment, such as endotracheal tubes, full bi-level positive airway pressure mask, and cervical collar brace can cause pressure ulcers. Endotracheal tube pressure may cause pressure ulcers on a patient’s lip (SITE PAPER 2). It’s important to re-secure the device often to release constant pressure. Cervical collars

Preventive Measures

However, there are preventative measures that can be taken to reduce the outcome of pressure ulcers from occurring. A well- known method to prevent pressure ulcers involve turning and repositioning the patient every two hours. It is suggested that the patient should be turned every two hours, alternate lateral and supine position (SITE PAPER 2). Also, placing a patient on a mattress specialized to reduce pressure ulcers may be highly effectives, as well. Low air mattresses and pressure redistribution mattresses are often used in these high-risk patients (STIE PAPER 2). According to (SITE PAPER 2), low-air-loss mattress acts to dry excessive moisten skin in patients while in bed.

Stages of Pressure Ulcers

The most common risk scale used in the United States are the Braden and the Norton scale (SITE PAPTER). The Braden scale is used to predict which patient may be at a higher risk of developing pressure ulcers. Once a patient develops a pressure ulcer, it is then categorized into stages. Deep tissues injury represent the beginning classification of wounds. Deep tissue injury is defined as a purple maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/ or shear (SITE PAPER 3). Next, stage I consists of intact skin with non-blanch able redness of a localized area usually over a bony prominence (SITE PAPER 3). During this stage, pain can be a factor along with firm to soft tissues under the affected area. Stage II includes partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (SITE PAPER 3). During this stage, the wound site may rupture or can be still intact. Stage III is when a full thickness tissue is loss (SITE PAPER 3). Subcutaneous fat may be visible but bone, tendon or muscle are not exposed (SITE PAPER 3). Stage IV consists of full thickness tissues loss with exposed bone, tendon or muscle (SITE PAPER 3). Slough or eschar may be present on some parts of the wound bed (SITE PAPTER 3). Due to muscle exposure, Stage IV wounds are the deepest. Last, unstageable is when full-thickness tissues loss occurs in a patient in which the base of the ulcer is covered by slough (yellow, tan, gray or brown) and/ or eschar (tan, brown or black) in the wound bed (SITE PAPER 3). In order to correctly categorize this wound, debridement must be done first. A specialized healthcare provider is responsible for determining the stage of each wound.

In areas such as the heels, scalp, malleolus, or ears, the lack of subcutaneous fat layer make progression of pressure ulcers from stage II to stage

The increased risk for skin breakdown and the development of pressure ulcers is related to changes in aging skin and to situations that occur in the acute care setting such as mobility, incontinence, and malnutrition (SITE BOOK Pottery& Perrry, pg 4).



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