What is a pressure ulcer?
A pressure ulcer (bedsore, decubitus) is severe damage to the skin as a result of permanent pressure on, and reduced blood supply in, a particular area of skin. It is a common complication in people admitted to hospital or a nursing home for another reason, and is a serious, sometimes life-threatening complication of hospital admissions. Pressure ulcers usually develop within the first 2 weeks of admission.
How does a pressure ulcer develop?
Pressure ulcers occur mainly when people must stay in bed for a long time or otherwise remain in one position lying or sitting for very long. They occur where the skin lies over a relatively protruding part of the skeleton. When the skin is “mangled” for long between bone and bed, a local oxygen shortage develops in the skin and the tissue beneath; if this lasts longer, the tissue dies (necrosis). The dead skin and underlying tissue disappear, resulting in a (often deep) wound called an ulcer. Well-known (and notorious) sites are the tailbone and the heels.
What does a pressure ulcer look like?
Pressure ulcers can be graded by severity:
- Stage I — the very beginning, marked by a red patch that, importantly, does not briefly disappear when pressed with a finger. Although not yet clearly visible, much damage has already been done.
- Stage II — the first serious damage becomes visible, usually a blister filled with bloody fluid or a dry, black epidermis; very superficial ulcers can also form. Only the epidermis and part of the dermis are involved.
- Stage III — the full thickness of the skin has died, and often part of the underlying fat, so there is now a deep ulcer, though the muscles beneath are not yet affected. The dead skin is yellow or black.
- Stage IV — the muscle tissue is also affected. Very deep wounds have formed (sometimes centimetres deep), often much larger than they first appear, with cavity formation and undermining of the skin.
The appearance can be misleading: the defect visible at the surface reveals only a fraction of the actual tissue death. A small surface wound can be just the “crater” of an enormous “volcano” of problems beneath, so for a good assessment (and as an essential first step in healing) the doctor will open up and inspect this properly.
Which factors can worsen a pressure ulcer?
Pressure ulcers can arise in anyone at any age; prolonged bed rest with little change of position (or long sitting in a chair) always plays the main role. Factors that can speed up or worsen the process include: inadequate nursing (too little help with repositioning); incontinence of stool or urine (softening the skin); reduced skin sensation (so the patient cannot signal pain in time); unconsciousness; poor nutritional state (patients often need extra protein and dietary enrichment); and bacterial skin infection.
Why are pressure ulcers so dangerous?
Pressure ulcers often heal slowly, and bacteria can grow in them and relatively easily reach the bloodstream. When bacteria enter the bloodstream, blood poisoning (sepsis) can develop — a life-threatening complication, especially in people with reduced immunity. Bacteria can also infect the underlying bone, which can lead to loss of bone structures and an even greater risk of sepsis.
How is a pressure ulcer treated?
When a pressure ulcer is discovered, optimal care techniques must be started at once, with extra attention to the mattress, nutrition and lying position. Local wound treatment follows several principles: removal of the necrosis (large dead pieces are removed surgically; superficial yellow coating can sometimes be removed with a necrosis-dissolving ointment; hypochlorite solution is used for very dirty, deep wounds); combating infection; sufficient protein-rich nutrition; and activating tissue repair with special wound care (hydrocolloid dressings for grades I and II; for grade III, sometimes also vacuum therapy to stimulate healing). Special anti-pressure mattresses that relieve the pressure on the wound area are used; in severe forms, special air mattresses automatically relieve the body’s pressure points (tailbone, heels).
Prevention is better than cure
Hospitals and nursing homes now pay much attention to preventing pressure ulcers, yet they remain an enormous problem, and afterwards it often turns out that much of it could have been prevented. Many institutions have “pressure-ulcer teams” (nurses, dermatologists and often a special consultant). Important recommendations: keep the patient moving or at least regularly changing position; ensure good nutrition; treat skin infections in time; and provide an adequate anti-pressure mattress in time.
When to see a doctor
Seek medical care promptly for a persistent red patch, blister or wound over a pressure point in someone who is bedbound or immobile, and urgently if there are signs of deep tissue damage or infection (fever, spreading redness, foul wound).