Did you know...?
1. Pressure Ulcers occur in up to 10% of patients in Hospital1
2. Pressure Ulcers affect up to 20% of patients in Nursing and Residential Care1
3. Pressure Ulcers cost the NHS between £1.4 and £2.1 billion each year2
4. Pressure Ulcers are part of the NHS 'High Impact Actions'3
What causes pressure ulcers?
Pressure ulcers
develop as a response to external forces causing localised ischemia
(a restriction in blood supply). It is generally believed that
external forces from direct pressure, shear and friction over bony
prominences cause stresses and strains on the tissue.
These stresses and strains occlude circulation, reducing
oxygen and other vital nutrients reaching the tissue.
Lymphatic drainage is also thought to be impaired, causing a
build of metabolic waste. Lets take a closer
look three main factors that cause skin damage:
Pressure
Pressure can be calculated by dividing weight by support surface area, hence the greater the support area, the lower the pressure. The pressure from a mattress when lying or sitting compresses skin and tissue between the surface of the mattress and the bony parts of the body. When skin and tissue is compacted between these two surfaces, capilliaries get compressed preventing them from carrying oxygen and other vital nutrients to the tissue.
Shear
Shear forces are parallel forces, sometimes described as stretching forces, caused by the effects of gravity. When an individual slides down or is dragged up a bed or chair, shear forces pull on the skin. When this occurs, the upper layers of skin can be pulled away from deeper layers of skin and tissue causing damage. This stretching force can rupture capilliaries, thus causing localised tissue damage.
Friction
Friction is a type of shear force that is limited to the skin but can damage the epidermis and result in a superficial ulcer5. Friction is commonly defined as the resistance present when one material rubs against another e.g. the rubbing of a bed sheet against the skin. This commonly occurs when individuals slide down the bed or chair causing abrasions or blisters.
Common locations of pressure ulcers
Who is at risk of developing pressure ulcers?
People may be at risk of developing pressure ulcers, often referred to as Bed Sores, for a number of reasons such as:
| - Immobility | - Obesity |
| - Malnourishment | - Continence issues |
| - Poor circulation | - Previous tissue damage |
People with certain skin types and those with particular underlying medical conditions are also vulnerable. The presence of pressure ulcers has been associated with an increased risk of secondary infection and a two to four-fold increase in the risk of death in older people in intensive care units.4
Understanding the environment and your patient
Many clinicians now use a SKIN or CARE Bundle which is a useful tool in preventing pressure ulcers. This typically includes observation and action elements that are designed to monitor and prevent pressure ulcer formation.
The SKIN Bundle
S - Support Surface
A high quality and properly maintained pressure reducing foam mattress is clinically proven to positively contribute to pressure ulcer prevention. If a patient sits out of bed, a pressure reducing cushion should also be used to assist in the prevention of damage to the buttocks.
K - Keep moving
Lying or sitting in one position for long periods of time can cause the skin to become damaged and eventually die due to lack of blood flow. Patients should be repositioned regularly and/or encouraged to re-position themselves.
I - Incontinence
Management of continence and keeping patients clean and dry is essential in preventing skin damage. Prolonged wetness to the skin (maceration) increases the risk of damage that can be caused by shearing. A skin inspection should include assessment of continence.
N -- Nutrition and Hydration
The skin, as the largest organ in the body, must be kept will hydrated. Patients should be encouraged or assisted to drink two litres of fluid per day. Good nutrition provides essential nutrients which in turn keeps the skin healthy. An underweight bony patient will be at greater risk of developing pressure ulcers. Similarly an obese patient will be at greater risk, due to immobility, and increased pressure caused by body weight.
Pressure Ulcer Classification
There are a number of methods for classifying the severity of a pressure ulcer. Leading organisations and agencies in pressure ulcer research have been involved in categorising/ grading pressure ulcers and have put together some useful tools to use.
Invacare has developed a Pressure Ulcer Classification poster based on the EPUAP research, which is available for you to download. If you require hard copies, please complete the Contact form.
There are a number of free educational resources available for you to download. To view them, please click here.
Healthcare Professionals - If you require further information, please contact you local Invacare Business Development Manager or use the contact us form
Members of the public - If you have any concerns about pressure ulcers, please contact your local Healthcare advisor
Useful Links
EPUAP Grading - http://www.epuap.org/pressure-ulcer-research/pressure-ulcer-grading-guide/
NPUAP Stages - http://www.npuap.org/resources.htm
Tissue Viability Society - http://www.tvs.org.uk/
Welsh Wound Network - http://welshwoundnetwork.org/
Wound Care Alliance - http://www.wcauk.org/
National Health Service - http://www.institute.nhs.uk/building_capability/hia_supporting_info/your_skin_matters.html
References
1. Clark M, Bours G, Defloor T. The prevalence of pressure ulcers in Europe. In Recent Advances in Tissue Viability (Ed M Clark), 2004, Quay Books, Salisbury
2. Bennett, G. Dealey, C. & Posnett, J. (2004) The Cost of Pressure Ulcers in the UK.
3. NHS Institute for Innovation and Improvement www.institute.nhs.uk
4. Bo, M., Massaia, M. et al. (2003) Predictive factors of in-hospital mortality in older patients admitted to a medical intensive care unit. Journal of the American Geriatrics Society
5. Bader, Dan et al. Pressure Ulcer Research: Current & future Perspectives, Springer, 2005