Pressure ulcers are defined as localised damage to the skin and underlying soft tissue. It is usually over a bony prominence or related to a medical/other device. They typically occur in patients with reduced mobility, where prolonged pressure on particular areas lead to the skin breaking down.
Pathophysiology
There are 4 main factors that interplay to form pressure ulcers:
- Pressure - irreversible tissue damage may occur as a result of relatively short exposures to high levels of pressure or longer exposure to lower levels of pressure.
- Shear - shear forces, typically generated when patients slide down in bed, may cause stretching and tearing of small blood vessels and contribute to pressure-induced damage
- Friction - alongside moisture, it causes superficial injuries and skin tears.
- Moisture - leads to moisture-associated dermatitis, and it decreases the stiffness of the stratum corneum and increases the coefficient of friction so that skin is more adherent to the contact surface.
Inadequate blood flow & ischaemia to the skin and soft tissues (as occurs in the setting of sepsis, hypotension, heart failure, or peripheral vascular disease) almost certainly contributes to tissue ischaemia and pressure ulceration.
⚠️ Risk factors
- Immobility
- Neurological impairment - leading to impaired perception of pressure that leads to failure to self-reposition.
- Older age
- Surgery - especially after hip fracture.
- ICU stay
- Urinary incontinence - as this leads to increased skin moisture.
- Diabetes - due to neuropathy, poor circulation and impaired healing.
- Peripheral vascular disease
😷 Presentation
- Ulcer - most commonly in the sacral area and over bony prominences.
- Discoloured skin - the skin may show non-blanching erythema, it may be purple/maroon.
- Painful skin
- Excessive exudate
- Odorous wound
🔍 Investigations
It is a clinical diagnosis based on examination. We should make a note of the size of the ulcer too.
- We can use the Waterlow score to assess risk of a pressure ulcer.
🧰 Management
Management of pressure ulcers:
All patients should be treated with:
- Pressure relief - this can be achieved through pressure-relief mattresses and regular moving of the patient.
- Dietary optimisation
- Pain relief
- Good hygiene and dressings -
- Skin care - particularly in the sacral region.
- Surgery - may be required for deep ulcers.
🚨 Complications
- Sepsis
- Cellulitis
- Osteomyelitis