Introduction to Pressure Ulcers ( Bed Sores)

Who is this guide for?

This simple guide to pressure ulcers is intended to be used as a brief overview by  anyone who has an interest in pressure ulcers, such as maintenance technicians, care home proprietor, care assistants as well as those that might be affected by them. We must point out from the outset that dynamic pressure relieving mattresses, irrespective of what the salesman says – should be treated as an aid to assist in the prevention and / or treatment of pressure ulcers (formerly known as bed sores / pressure sores) and NOT be used as a curative device in its own right.

We say this as their are so many different factors involved that can affect decubitus (pressure ulcers) such as moisture and perspiration, nutrition, hydration, medication, illness, mobility  and hygiene. From a safety perspective we always advise clinical intervention be it simple advice from your district nurse through to complex wound care in more serious cases. Some people at risk of pressure ulcers wish to live independently within their own homes and others, perhaps due to several of the aforementioned factors will require constant repositioning, monitoring and care.

The purpose of this guide is to give a simple and brief overview of the subject and also to indicate successful use of airflows in various care settings. Finally, which ever airflow mattress that you decide to use – make sure that you secure a substantial trial period and involve the opinion of your clinician.

Whilst the Water low score is rarely used in modern training establishments, it is still popular in some overseas countries and so we have used the Waterlow Score as a guide to indicate the risk categories which are as follows:

•  10 + At Risk
• 15 + High Risk
• 20 + Very High Risk

For more information on waterlow please visit www.judywaterlow.co.uk

This guide cannot hope to cover all the information available – nor does it set out to do so. It aims to give basic information and stimulate further reading and discussion where necessary. We strongly suggest that nurses, matrons and other members of the care team secure the appropriate tissue viability training from one of the many wound care organisations. Further details are available on our website, www.squirrelmedical.co.uk

 

The Threat of Litigation

Pressure ulcers have plagued healthcare providers throughout time. Sadly, despite advances in knowledge and technology, they remain an issue of concern to this day. With an aging society and a rising expectation of healthcare practice, they have become a national concern.

The development of pressure ulcers is often misunderstood. To the sufferer, they are at best distressing and painful, and can lead to social isolation. At worst, they can place an enormous burden on the sufferer’s health and can trigger complications that threaten life itself. The distressing fact is that in most cases pressure ulcers are quite preventable. The threat of litigation, (an increasingly common result of pressure damage) together with the colossal costs involved in the treatment of pressure ulcers makes this a subject of huge importance to us all.

What is a Pressure Ulcer?

Pressure ulcers may initially appear as red discoloration of the skin that does not fade when finger pressure is applied. This may be accompanied by local heat and swelling. This is known as Grade 1 damage.

When tissue is starved of oxygen, it dies. If the damage is limited to tissue near the surface, there may be simple blistering, however, if deeper structures are involved, the dead tissue may look black. This discolouration may be masked in people with dark pigmented skin, and superficial damage, which is often an early sign of deeper problems, may go unnoticed. Damage may be much more severe than at first apparent.

Eventually the damaged tissue will break down, revealing an ulcer that may penetrate through to bone or internal organs, (Grade 4). Given the right circumstances, any area of tissue that lies over a bone may form a pressure ulcer. These areas include the sacrum, heels, toes, head, elbows and shoulder blades, whilst lying on the back; ankles, knees, hips, ribs, shoulders and ears when lying on the side.

 How common are Pressure Ulcers?

Studies have shown that the prevalence of pressure ulceration across the United Kingdom is unknown. Some studies however have shown that in some care settings, figures of 10 to 80 percent have been recorded. National figures are hard to establish due to the problem of data collection and varying methods of interpreting the information. However, what can be seen is that with careful monitoring and a proactive approach, huge reductions can be made. Indeed, where good education is provided to caregivers, pressure ulcers are extremely rare.

How are Pressure Ulcers Caused?

A pressure ulcer is a sore caused as a result of the interruption of blood supply to soft tissues. There are three main ways for this damage to be caused – pressure, friction and shear.The patient’s weight is transferred through the bone structure, which in turn presses on the sensitive tissue and the skin that covers it. The tissue is then trapped between the bone and the external surface. This pressure keeps the blood from flowing to the area to deliver oxygen and remove waste, leading to tissue death. And a pressure ulcer forms.

If friction is applied to the skin at the same time, the top surface may be torn off or damaged, causing blistering. Added to this, if a patient slips down a slightly raised or profiled mattress, the bony projections of the pelvis will tend to distort the internal tissues. This movement, when applied to soft tissues is called ‘shear.’ Shear forces stretch and twist blood vessels, making them collapse and cutting off the blood supply. Pressure ulcers occur when one or more of these three mechanisms – pressure, friction or shear – are applied to a person’s tissue.

 Extrinsic and Intrinsic factors

A number of factors will put a person at risk of skin damage. Those in the surrounding environment are known as extrinsic factors. These may include immobility, poor positioning and poor handling techniques, leading to patients slipping down the bed or being dragged across surfaces; damp bedding; or the use of incorrect cushions, splints or mattresses.

The term intrinsic factors is used to describe features within the patient’s own condition that can increase the risk of damage. These include old age, a poor state of nutrition, dehydration, or the presence of underlying illness. In many cases, patients are exposed to a number of different external and internal factors at the same time.

Successful prevention entails recognising those at risk of damage, identifying what preventative action needs to be undertaken, implementing this strategy, documenting the care or action taken, and regularly reassessing the situation. Many Pressure ulcers happen as a result of ignorance.

Most ulcers result from a combination of factors. Typical examples include a person with poor nutrition rubbing against a surface, such as a toilet seat, wheelchair, hoist sling, side rail or a bed sheet. Other contributory factors include prolonged exposure to moisture from perspiration or urine, as well as high and low temperatures.

If such a person is left on an unsuitable surface, such as a cold, hard, plastic toilet seat (possibly because of constipation), that could precipitate ulceration.

Hard surfaces cause faster ulceration. Hard surfaces such as ward trolleys and (substandard) compressed foam mattresses tend to produce a faster ulceration. This is because the support surface is unable to mould to the patients’ contours. Pressure is therefore concentrated over bony prominences such as the heels, whilst the lower lumbar area is unsupported.

 Patient Repositioning

Florence Nightingale is credited, amongst others, for implementing a two-hourly turning or repositioning regime. This is one of the factors credited with saving thousands of lives in the field hospitals of the Crimea. Two hours is still the generally accepted period that tissue can tolerate pressure on a mattress without damage occurring. However, for some individuals, even this can be too long, particularly if specialist mattresses are not being used.

 Nutrition and Hydration

Another contributory ‘intrinsic’ factor is a client’s nutritional state, as a poor diet and consequent weight loss removes body padding and exposes bony prominences.

Also, dehydration reduces the adequate oxygenation of tissue, thus affecting tissue strength and stability. If damage does occur, this can also delay tissue repair. Re-hydration coupled with a good nutrient rich diet should be given primary consideration.

People who are diabetic are particularly at risk. Poor healing rates, along with alterations in blood circulation to tissues and frequently, a reduced nerve supply to the extremities, (peripheral neuropathy) make them more prone to damage and more difficult to treat. For this reason people with diabetes need careful blood sugar control and even greater attention and prevention than non-diabetic individuals.

Hygiene and Skin Care

Whilst a better nutritional state and improved hydration is extremely important, so is good hygiene. Urine left on the skin rapidly breaks down into ammonia. This chemical strips away the natural oils in the skin and can result in severe damage. Cleaning should be undertaken delicately and regularly, as moisture, including almost unnoticeable perspiration, can give a clammy feel to the skin and can again precipitate skin damage.

Soaps, particularly the highly perfumed varieties, also strip away the skin’s natural oils and should be avoided. Where needed, skin cleansers and soap substitutes should be used to maintain skin health. Regular use of moisturisers and emollients can help protect the skin and restore the correct moisture balance. Where regular incontinence is a problem, skin barrier preparations should be considered as a preventative regime.

Pressure Ulcers can occur in one hour

Pressure damage can develop in as little as one hour, and can be caused simply by leaving an immobile and vulnerable person on an inappropriate bed or support surface.

Ulceration can happen almost immediately, particularly where there is friction damage. Vulnerable people should be regularly assessed – constant vigilance is essential.

Risk Assessment

People at risk of skin damage can be easily identified by using a Risk Assessment Tool. One such system is the internationally recognized Waterlow Score, which was developed by the pioneering British nurse, Judy Waterlow. Her lifetime’s work has saved many lives by helping nurses and carers identify those at risk of pressure ulcer development. Judy has made her work widely available and easily understood.

 The Waterlow Score

The Waterlow Score offers an easy to use, points based scoring system. It allocates a points value to a number of the common risk factors, including the person’s age, mobility, continence, weight, skin condition, nutritional state and medical condition. When these are added up they provide a total, known as the waterlow score. A score of 10 or more is considered ‘At risk’, 15 plus, ‘High risk’ and 20 plus, Very High Risk. Waterlow Cards should be available to all care staff working in care establishments. The system is backed up by an excellent and easy-to-read pressure ulcer prevention manual that should be read by everyone connected with or interested in the prevention of pressure ulcers. For more information please visit our website on: www.squirrelmedical.com

Health & Safety Policy

Organisations need to ensure that the prevention of pressure ulcers is part of their strategic approach to care. They need to make sure that it is adopted into the organisation’s health and safety policy, that regular risk assessment is carried out and that sufficient, appropriately trained and aware staff are available to administer the correct nursing care.

There are, of course, numerous other causes of skin injury, all of which must be considered at both ward and executive level. If pressure ulcers are caused accidentally, through ignorance of the vulnerability or fragility of the client, is the second time still an accident.

Some care providers have no recorded instances of pressure ulcers among their clients. In most cases this is due to good fundamental care, where there is a high standard of awareness amongst all personnel within and connected with the care setting, from executives and administrators to care assistants, maintenance persons, and cleaning staff.

Good care procedures and practices are put in place and monitored to ensure they are being adhered to. Good care should be seen as a right not a privilege. The first step to achieving this goal should be an improved awareness of the issue of pressure damage; the next, a strategic approach to the problem that addresses patient needs effectively.

Numerous pressure relieving items are available that will help to position the body, spreading excess pressure and helping in treating or preventing pressure ulcers. The theory and benefits of each may be summarised as follows, bearing in mind that all such items should be regarded as aids to care rather than substitutes for care.

Alternating Air Mattresses

An alternating air mattress is made up of a series of air cells, which are inflated with an air pump. Cells inflate in a cyclical manner – one set of cells supporting the patient whilst the others deflate, enabling the patients’ tissues to perfuse with oxygenated blood. The cycle, and therefore the pressure of the supporting cells, changes approximately every ten minutes throughout the entire surface area of the bed. This mimics the subtle movements we all make during rest and sleep.

Their are numerous considerations and factors to review with regards to dynamic air mattresses. Their designs have changes profoundly during these past two years. Some are better at reducing neurological pain whilst others can enable safe wheelchair transfer. Mattresses can be supplied either as an NHS style mattress or can be modified to look like incredible domestic divans. Please see the clinical section www.squirreldiamond.com

There are several reputable suppliers of quality preventative equipment that will generally offer a good after sales service. When preparing to obtain new equipment it is important to negotiate (depending on the product) a trial period to establish the absolute suitability of the equipment to the clients’ needs, and replacement in the event of mechanical failure, as lengthy repair times can cause problems.

Cleaning and Decontamination

Users of pressure relieving equipment are often some of the most vulnerable people, and are being protected by that equipment against what could easily become an open wound. It is very important to have a strict cross infection policy, as it is all too easy to transfer a contaminated mattress from one person to another. This is a very important matter, and one where we advise further study. (www.squirrelmedical.com).

A huge array of decontaminates, chemicals, soaps and wipes is now available to clean and decontaminate preventative equipment, however, all too often these are simply not used as often or as thoroughly as they should be. In fact, some of the cleanest and healthiest care homes use nothing more than warm soapy water coupled with a strict and thorough cleaning regime.

It is very important that mattresses and special cushions are regularly cleaned and decontaminated when soiled, between users, and prior to being despatched for repair or servicing

Summary

The prevention of pressure ulcers must be our collective priority, backed up with accessible and easily understood training. This should be coupled with professional tissue viability training for those who administer treatment or have a closer involvement with care. Those responsible in care situations should ensure that regular risk assessments are made for each and every resident and that their level of risk is recorded.

Nurses and carers should be allowed whatever time is necessary to transfer, turn, or reposition those in their care in safety, and all instances of ulceration should be reported, logged and investigated.

Too much reliance should not be made on preventative aids – correct diet, hydration, movement, turning and nursing care is just as important when using pressure relieving mattresses as with any other mattress. Most pressure ulcers are preventable – the development of an ulcer may indicate a deviation in the standard of care being given.

There is a real threat that this problem will continue to grow and with it the risk of legal proceedings. Ironically, the resultant costs in terms of treatment and litigation far outweigh the comparatively small levels of investment needed to prevent damage.

As mentioned, this Guide does not cover all the information available. It aims to give basic information and stimulate further reading and discussion where necessary. We strongly suggest that nurses, matrons and other members of the care team, such as occupational therapists, secure the appropriate tissue viability training from one of the many wound care organisations. Further details are available on our website, www.squirrelmedical.co.uk.