Pressure Injuries
Pressure sores
Areas of skin necrosis due to pressure-induced ischaemia found on sacrum, heels, over greater trochanters, shoulders, etc. Also known as decubitus ulcers or bedsores. Incidence higher in hospital (new sores form during acute illness) but prevalence higher in long-stay community settings (healing takes months/years). Average hospital prevalence 5-10% despite drives to improve education and preventative strategies. The financial and staffing resource burden of pressure sores is huge.
Grading
0 Skin hyperaemia
I Non-blanching erythema
II Broken skin or blistering (epidermis ± dermis only)
III Ulcer down to subcutaneous fat
IV Ulcer down to bone, joint or tendon
▶2 hrs of tissue ischaemia is sufficient for the subsequent development of an ulcer and the causative insult often occurs just prior to or at the time of admission (on ED trolleys, intraoperative, at home). There is considerable lag between the ischaemic insult and the resulting ulcer. Grade I erythema often progress to deep ulcers over days/weeks without further ischaemic insult. Inspect sacrum and heels at least daily.
Risk factors
Include age, immobility (especially postoperative), low or high body weight, malnutrition, dehydration, incontinence, neurological damage (either neuropathy or decreased conscious level), sedative drugs, vascular impairment.
Several scoring systems (eg Waterlow score) combine these factors to stratify risk. They aid/prompt clinical judgement of individual patient risk.
Mechanisms
Pressure—normal capillary pressure 24-34mmHg—pressures exceeding 35mmHg compress and cause ischemia. This pressure is easily exceeded on a simple foam mattress at pressure points such as heels
Shear—where skin is pulled away from fixed axial skeleton small blood vessels can be kinked or torn. When a patient is propped up in bed or dragged (eg during a lift or transfer) there is considerable shear on the sacrum
Friction—rubbing the skin decreases its integrity especially at moving extremities, eg elbows, heels. Avoid crumbs, drip sets and debris between patient and sheets. Massage of pressure areas no longer recommended
Moisture—sweat, urine, and faeces cause maceration and decrease integrity
Management
Prevention—demands awareness—NICE guidelines suggest all patients are risk assessed within 6hr of admission (
www.nice.org.uk, clinical guideline 29 (2005)). Regular reassessment during hospital admission should occur especially if condition of patient changes
Turning and handling—there is no evidence to suggest how often immobile, high-risk patients should be turned in bed. Two-hourly turns are historically based and rarely achieved. Frequency should be judged individually. Modern mattresses decrease frequency but don’t eradicate need for turns. Avoid friction and sheer by using correct manual handling devices. Consider limiting sitting out to 2hr. Encourage early mobilization, optimize pain control, minimize sedative drugs
Pressure-relieving devices—consider both beds and chairs. There are few RCT data to compare but most hospitals have access to (in order of increasing pressure reduction and cost)
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