Overview
Definition:
Pressure sores, also known as pressure ulcers or decubitus ulcers, are localized injuries to the skin and underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear.
Epidemiology:
The incidence of pressure sores in surgical patients can range from 5-15%, significantly higher in critically ill or prolonged immobility cases
Risk factors include immobility, malnutrition, moisture, friction, and impaired sensation.
Clinical Significance:
Pressure sores are preventable but can lead to significant patient morbidity, including pain, infection (cellulitis, osteomyelitis, sepsis), delayed wound healing, and increased healthcare costs
They are a marker of quality of care and can impact patient satisfaction and legal outcomes.
Risk Assessment
Risk Factors:
Immobility: Prolonged bed rest, paralysis, cast immobilization, surgical dressings
Sensory Deficit: Neuropathy (diabetic, spinal cord injury), anesthesia
Moisture: Incontinence, perspiration, wound drainage
Nutrition: Malnutrition, low albumin, dehydration
Friction & Shear: Repositioning, sliding down in bed
Impaired Circulation: Peripheral vascular disease, edema
Age: Elderly patients have thinner, less elastic skin
Comorbidities: Diabetes, cardiovascular disease, renal failure, cancer.
Assessment Tools:
Braden Scale: Widely used, assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear
Norton Scale: Older scale, assesses physical condition, mental state, activity, mobility, and incontinence.
Frequency Of Assessment:
Initial assessment upon admission, and then regularly throughout the hospital stay
For surgical patients, reassessment is crucial post-operatively, during prolonged recovery, and with any change in clinical status
Daily reassessment is often recommended for high-risk individuals.
Prevention Strategies
Skin Care:
Regular inspection of skin, especially over bony prominences
Gentle cleansing with mild soaps and water
Promptly clean and dry skin after incontinence episodes
Avoid massaging bony prominences, as this can damage underlying tissue
Moisturize dry skin to maintain its integrity.
Support Surfaces:
Use of specialized mattresses and cushions designed to redistribute pressure
This includes static air, low-air-loss, dynamic air, and foam surfaces
Regular turning and repositioning schedule, typically every 2 hours, or as indicated by the patient's risk assessment and skin tolerance
Ensure adequate support under heels.
Nutrition And Hydration:
Adequate protein and calorie intake are essential for tissue repair and health
Nutritional assessment and supplementation may be required
Ensure sufficient fluid intake to maintain skin hydration and circulation
Consult with a dietitian for personalized recommendations.
Mobilization And Positioning:
Encourage early mobilization and active/passive range of motion exercises as tolerated
Proper positioning techniques to avoid pressure points and shear forces
Use of pillows and wedges to offload pressure
Avoid positioning directly on bony prominences like the sacrum or trochanters.
Management Of Early Sores
Staging:
Stage 1: Non-blanchable erythema of intact skin
Stage 2: Partial-thickness skin loss involving epidermis and/or dermis
Stage 3: Full-thickness skin loss involving subcutaneous tissue, may extend to underlying fascia
Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle
Unstageable: Full-thickness tissue loss where the base is covered by slough or eschar.
Treatment Principles:
Relieve pressure from the affected area completely
Keep the wound clean and moist
Use appropriate dressings to protect the wound, absorb exudate, and promote healing
Nutritional support is critical
Pain management as needed.
Dressing Selection:
Stage 1: No dressing typically required, focus on pressure relief
Stage 2: Hydrocolloids, transparent films, or foam dressings
Stage 3 & 4: Advanced wound dressings such as alginates, hydrofibers, or negative pressure wound therapy (NPWT) may be considered, depending on wound characteristics
Regular debridement may be necessary.
Surgical Considerations
Prevention During Surgery:
Use of specialized operating table pads, gel pads, and positioning devices to minimize pressure and shear forces during prolonged surgical procedures
Careful attention to patient positioning and avoiding pressure on vulnerable areas
Regular checks of pressure points during long surgeries.
Surgical Reconstruction:
For non-healing or large pressure ulcers (typically Stage 3 & 4), surgical intervention may be indicated
Options include debridement, flap closure (e.g., rotational, advancement flaps), or skin grafts
The goal is to remove necrotic tissue and cover the defect with well-vascularized tissue to promote healing and prevent recurrence.
Anesthesia And Nerve Protection:
Anesthesiologists play a role in patient positioning and awareness of pressure points
Neuromuscular blockade in long surgeries can mask patient discomfort, necessitating vigilant positioning and padding
Potential for nerve compression injuries needs to be considered and managed.
Complications
Infection:
Cellulitis: Superficial bacterial infection of the skin and subcutaneous tissues
Osteomyelitis: Infection of the bone, often deep and difficult to treat, requiring prolonged antibiotics and possibly surgical intervention
Sepsis: Systemic inflammatory response to infection, life-threatening.
Fistula Formation:
Development of abnormal passages, particularly between the ulcer base and underlying hollow organs like the rectum or vagina, often associated with malignancy or severe infection.
Contractures And Functional Loss:
Scarring and tissue loss can lead to limitations in range of motion and functional impairment, particularly affecting mobility and quality of life.
Recurrence:
Pressure sores have a high recurrence rate, especially if underlying risk factors are not adequately addressed
Surgical reconstruction aims to reduce this risk by providing stable coverage and reducing pressure points.
Key Points
Exam Focus:
High-yield facts include the stages of pressure ulcers, the Braden Scale components and interpretation, and the principles of prevention (pressure relief, skin care, nutrition, mobility)
Understand the indications for surgical intervention and common reconstructive techniques.
Clinical Pearls:
Prevention is paramount
Early recognition of redness over bony prominences in surgical patients is critical
Aggressive pressure relief and repositioning are the cornerstones of care
Document all assessments and interventions meticulously.
Common Mistakes:
Failing to assess risk regularly
Inadequate pressure relief
Overlooking moisture-associated skin damage
Not considering nutritional status
Using incorrect dressings for the wound stage
Inadequate follow-up after discharge, leading to recurrence.