Pressure ulcers (also known as ‘bed sores’, ‘pressure sores’ or ‘Decubitus Ulcers’) is a condition in which areas of skin and associated tissues degenerate and ulcerate, due to application of prolonged pressure on the bony prominences present in the body (Merck, 2005). The skin overlying the bony prominence begins to get necrosed when the portion is compressed (or weight is applied without constant shifting) for long periods of time. Friction and shearing forces could also lead to pressure ulcers (Merck, 2005). The sustained pressure would disrupt the blood supply to the skin and associated tissues leading to tissue hypoxia and formation of pressure ulcers (Mayo, 2006).
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If proper nursing care is provided, there are good chances that pressure ulcers could be prevented (Bergquist, 2007). In nursing care setting, the higher incidences of pressure ulcer may be considered to be a sign of provision of poor quality nursing care (Bergquist, 2007). Pressure ulcers can also develop when an elderly person has been hospitalized for prolonged periods for a general medical problem (Bergquist, 2007). The chances of elders developing pressure ulcers when hospitalized are about 2 to 29 % (Bergquist, 2007). In homes for the aged, the chances of developing pressure ulcers is about 3 to 38 %, and is about 6 to 29 % in those who receive care in their home (Bergquist, 2007).
Pressure ulcers usually occur in those inpiduals who have developed injury of the spinal cord and also those with paralysis (Mayo, 2006). Inpiduals who follow a sedentary life-style and who a wheelchair bound are at the greatest risk of developing pressure ulcers (Mayo, 2006). The risk of developing pressure ulcers in inpiduals with nerve injury is the highest because they may not be aware of the compression to certain parts of the body. When a spinal cord injury occurs, the inpidual is unable to sense pain or uncomfortable sensations in a particular portion of the body. Hence, the cancers of further damage are very high (Mayo, 2006).
The other factors that could be held responsible for pressure ulcers include excessive moisture, emotional stress and presence of comorbid conditions (Bergquist, 2007). In all cases, the nurses should be able to assess the risk for developing pressure ulcers. The Braden’s scale is frequently utilized to determine the risk of developing pressure ulcers depending on the presence of certain risk factors (Bergquist, 2007).
Pressrue ulcers are more common in inpiduals above the age of 70 years. In such inpiduals, the skin may be slightly atrophic and thin, and has greater chances of getting degenerated when pressure is applied for prolonged periods (Mayo, 2006). In the US, about 1.3 to 3 million people suffers from pressure ulcers (Merck, 2005). Pressure ulcers develop in about 33 % of all inpiduals above the age of 70. Inpiduals who are bedridden, follow a sedentary lifestyle, do not exercise enough, are wheelchair bound, suffer from injuries to the spinal cord or paralysis, etc, are also at a higher rate of developing Decubitus ulcers (Hunter, 1996, pp. 958).
Inpiduals who suffer from fractures of the neck of the femur are also bound to develop this disorder. When the ulcers are deep, the chances of complications and fatalities are very high. Some of the common complications that may develop include infection, osteomyelitis and septicemia (Bergquist, 2007). Besides, the chances of the lesion not healing properly or in normal periods of time are quite high.
About 50 % of the lesions heal after 4 weeks and about 40 % heal after 6 months (Bergquist, 2007). The other factors that can be held responsible for the development of the ulcers include several disorders which makes movement difficult (such as arthritis, paraplegia and apathy), disorders in which the nerve sensations are reduced, certain disorders affecting the blood vessels (such as arthrosclerosis which may be seen in diabetes, hypertension, high cholesterol levels and smoking), malnutrition, dementia, stroke, corticosteroid use, chronic alcoholism, malignant diseases, etc (Hunter, 1996, pp. 958).
The pressure ulcers develop in the region where the bone compresses the overlying skin and the subcutaneous tissues for prolonged periods of time. The lesions begin as a small area of redness, and slowly get converted into a blister. The blister cannot tolerate the pressure and hence ruptures to form erosion (Hunter, 1996, pp. 958). The ulcer should be treated immediately, as it may progress further to involve the deeper layers of the skin. The lesion may get sloughed to form a black eschar.
This further gets infected with Pseudomonas aeruginosa bacteria. Foul odor may be emitted from the affected region (Merck, 2005). In case of septicemia, several constitutional symptoms such as fever, headache, malaise, lymphadenopathy, etc, may be present. Several portions of the body having bony prominences are at a high risk of developing pressure sores such as the sacrum, greater trochanter, calcaneous tuberosity, knees, condyles, toes, coccyx, iliac crest, shoulders, lateral malleolus, ischial tuberosity, etc (Hunter, 1996, pp. 958). The chances of developing pain and tenderness following pressure ulcer varies from 33 to 87 %.
The diagnosis of pressure sores is made based on the history, symptoms, signs, physical examination, and diagnostic tests. These include blood tests, X-rays, cultures and skin biopsy. A thorough physical examination is performed to determine the extent and depth of the lesion (Hunter, 1996, pp. 958). Wound culture tests and antimicrobial sensitivity tests are required to determine the causative organism. The bacterial count usually exceeds 100, 000 bacterial cells per gram of tissues. X-rays, bone scans and MRI scans may be required to determine involvement of the underlying bone (Merck, 2006). Urine and Stool tests are also required to determine the presence of incontinence (Mayo, 2006). Biopsy may be required to confirm the diagnosis and rule out the presence of cancer (Mayo, 2006).
Firstly, the lesion should be taken care of immediately, as if treating a wound. The dead and the degenerating tissues, along with the slough should be removed and the lesion should be thoroughly debrided using saline along with 0.5 % silver nitrate solution (Hunter, 1996, pp. 958). An antibacterial ointment should be applied over the lesion and a bandage should be placed. If the lesion causes a huge loss of tissues, a skin graft should be transplanted and/or sutures should be placed (Hunter, 1996, pp. 958). Antimicrobial agents may be required either orally or in the form of injections to treat the infection. The cause of pressure ulcers should be treated appropriately (Hunter, 1996, pp. 958). Any potential risk factors should be removed. A soft mattress or cushion should be utilized for sleeping and sitting. The inpidual should consume a balanced diet and should ensure that enough exercises are performed in a day. Whilst sleeping or resting, the inpidual should be turned every few hours to ensure that pressure over certain portions of the skin is not excessive.
Nurses should ensure that the skin is kept clean and dry. Moisturizers should be applied to maintain the integrity of the skin. The inpidual should avoid applying pressure on the affected portion of the skin (Cull, 1996, pp. 1101). Any shearing or friction force application should be avoided as these forces tend to slide over the tissues and cause injuries to the skin. The nurses should educate the patients to examine the skin especially where bony prominences are present in order to identify the presence of pressure ulcers. Incontinence should be taken care of adequately. Sedation should be avoided in elders as it may worsen the risk of developing pressure ulcers. Cleanliness of the skin should also be maintained (Bergquist, 2007).
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