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Pressure Sores

A. JABBAR DENTAL CLINIC

Sadia Khan

Overview

A pressure sore is an area of skin damage that develops due to prolonged and severe pressure on the skin. 
&nbsp;

The weight of an individual against a surface below causes pressure to be applied to the skin, soft tissue, muscles, and bones. This prolonged and severe pressure results in skin damage, causing the formation of pressure sores. They can occur anywhere but are most common on the skin overlying the bony areas of the body, such as the ankles, hips, tailbone, heels, and elbows. Pressure sores can also develop inside the mouth, especially due to intubation or ill-fitting dentures.

An estimated 3 million people in the United States are affected by pressure sores<a href="#accordion">[10]</a>. Although pressure sores can affect anyone, it most frequently affects bedridden people. Men have a higher incidence due to the greater frequency of traumatic spinal cord injuries.

As per German research that examined the prevalence in more than 18,000 patients staying in long-term care facilities, the frequency of pressure injuries has dropped from 12.5% in 2002 to 5% in 2008<a href="#accordion">[1]</a>. This decline is assumed to be the result of better preventative and effective management techniques.

A greater rise in the incidence of pressure injuries occurs as patients transition from the age range of 40&ndash;58 years to the age range of 75 years or beyond<a href="#accordion">[1]</a>. Approximately two-thirds of pressure injuries occur in people aged 70 or above<a href="#accordion">[1]</a>.

If left untreated, pressure sores can lead to life-threatening infections, such as cellulitis and sepsis. In 2019, pressure sores accounted for an estimated 24,400 deaths worldwide<a href="#accordion">[9]</a>.&nbsp; 
&nbsp;

There are no specific subtypes of pressure sores.&nbsp;&nbsp; 
&nbsp;

Signs and Symptoms

The following signs and symptoms point to a pressure sore:

<ul>
	<li>Pain, burning, or itching in the affected area</li>
	<li>Skin discoloration</li>
	<li>Skin may be red and warm to touch</li>
	<li>Skin may feel spongy or hard</li>
	<li>Open sore</li>
	<li>Pus- or fluid-filled sore</li>
	<li>Swelling 
	&nbsp;</li>
</ul>

In some people, especially those with dulled senses, pressure sores will not cause any pain or symptoms. 
&nbsp;

An infected pressure sore can result in:

<ul>
	<li>Fever and chills</li>
	<li>Foul-smelling sore</li>
	<li>Pus or green-colored discharge</li>
	<li>Severe pain 
	&nbsp;</li>
</ul>

In wheelchair users, pressure sores typically develop on the skin overlying the following areas:

<ul>
	<li>Tailbone or buttocks</li>
	<li>Shoulder blades and spine</li>
	<li>Backs of arms and legs where they rest against the chair 
	&nbsp;</li>
</ul>

For individuals who are bed-bound, pressure sores may occur on the following sites:

<ul>
	<li>The back or sides of the head</li>
	<li>The shoulder blades</li>
	<li>The hip, lower back, or tailbone</li>
	<li>The heels, ankles, and skin behind the knees 
	&nbsp;</li>
</ul>

Causes

A pressure sore is mainly caused by sustained pressure. The prolonged pressure cuts off the blood supply to the affected area, causing skin damage. Two to three hours of cut-off blood supply can result in a pressure sore. 
&nbsp;

The following factors contribute to the formation of pressure sores:

<ul>
	<li>Pressure - Prolonged or severe pressure cuts off blood supply, causing skin damage. As the overlying skin dies, it breaks down and forms an open sore or ulcer. Thus, paralyzed or unconscious people are most at risk as they are unable to move their positions.</li>
	<li>Friction - Repeated friction against clothing or bedding causes the top layer of the skin to wear away. In the elderly, this can make their fragile skin more prone to injury.&nbsp;&nbsp;&nbsp;</li>
	<li>Shear - This causes the skin to be pulled in the opposite direction, reducing blood flow to the skin. Shear can occur when the head of the bed is elevated and the person slides down in bed. However, the skin over the tailbone may stay in place, getting stretched in the opposite direction.</li>
	<li>Moisture - Urine, feces, or sweat can damage the epidermis or increase skin friction. Thus, contributing to the formation of pressure sores. 
	&nbsp;</li>
</ul>

Diagnosis

There are no specific screening tests for pressure sores.

Pressure injuries are typically diagnosed during a physical exam. The following are some of the criteria the doctor may use to assess the ulcer: 
&nbsp;

<ul>
	<li>The size and depth of the ulcer.</li>
	<li>The type of tissue, such as skin, muscle, or bone, that is directly impacted by the ulcer.</li>
	<li>The color of the affected skin.</li>
	<li>The extent to which the ulcer causes tissue death.</li>
	<li>The state of the ulcer, including if it&#39;s infected, has a strong odor, or is bleeding. 
	&nbsp;</li>
</ul>

The depth of the wound determines the stage of the pressure sore. It can be divided into four stages. These include the following: 
&nbsp;

<ul>
	<li>Stage 1 - Early symptoms of pressure ulcer, such as. skin discoloration, warm skin, redness, and itchiness may be seen in the affected area. In those with lighter skin tones, the skin looks red; in people with deeper skin tones, it appears blue or purple. When pushed with a finger, the skin doesn&#39;t blanch (turn white).</li>
	<li>Stage 2 - This is characterized by an open wound or blister, surrounded by discolored skin.</li>
	<li>Stage 3 - The top two skin layers and the fatty tissue are affected. The ulcer has a crater-like appearance.</li>
	<li>Stage 4 - The ulcer is deep enough to involve the muscles, bones, and tendons. 
	&nbsp;</li>
</ul>

In severe cases, your doctor may perform a biopsy or a sample of the fluids and tissue in the ulcer, and send it to a lab for testing. This can help test for infections. Other tests used to check for infections include blood cultures or tests. In the case of osteomyelitis, X-rays, or MRIs may also be conducted. 
&nbsp;

Treatment

Depending on the stage, pressure sores can be treated in a variety of methods. Once the stage and severity are confirmed, the wound has to be cleaned, often with a saline solution. Following cleaning, the wound must be maintained clean, moist, and bandaged appropriately. There are several different types of bandages the doctor may use to dress the wound. These consist of: 
&nbsp;

<ul>
	<li>Water-based gel (hydrogel) with a dry dressing</li>
	<li>Foam dressing</li>
	<li>Hydrocolloid dressing</li>
	<li>Alginate dressing (made from seaweed) 
	&nbsp;</li>
</ul>

Debridement is occasionally required. This procedure removes dead tissue from the incision. Debridement is a critical step in the recovery process. It transforms the wound from one that is chronic and long-lasting to one that is acute and recent. Debridement comes in many forms. These techniques consist of:

<ul>
	<li>Ultrasound: The dead tissue is removed using sound waves.</li>
	<li>Irrigation: Washing out dead tissue with fluid (typically under pressure).</li>
	<li>Laser: Concentrated laser beams help remove the dead tissue.</li>
	<li>Biosurgery: Maggots are used to eradicate bacteria from wounds.</li>
	<li>Surgery: Performing surgery to remove the dead tissue and close up the incision. A skin graft may be required to close the wound.</li>
	<li>Topical: Enzyme ointments or honey of a medical grade. 
	&nbsp;</li>
</ul>

The following measures can also help improve the healing of a pressure sore:

<ul>
	<li>Frequently changing the patient&rsquo;s position</li>
	<li>Using static foam or dynamic mattress to reduce pressure on the sore</li>
	<li>A healthy, balanced diet</li>
	<li>Oral antibiotics 
	&nbsp;</li>
</ul>

If left untreated, pressure sores can result in life-threatening complications. 
&nbsp;

Cellulitis: This is a bacterial infection of the skin. Inflammation, swelling, and warmth are common symptoms. Cellulitis can spread to other parts of the body, causing further complications, such as:

<ul>
	<li>Osteomyelitis: An infection of the bone</li>
	<li>Infectious arthritis - An infection of a joint</li>
	<li><a href="https://merisehat.pk/disease/necrotizing-fasciitis">Necrotizing fasciitis</a></li>
	<li>Sepsis: A life-threatening infection of the blood.</li>
	<li><a href="https://merisehat.pk/disease/bacterial-meningitis">Meningitis</a>: An infection of the brain and spinal cord.</li>
	<li>Endocarditis: An infection of the heart. 
	&nbsp;</li>
</ul>

Moreover, non-healing, long-term wounds can develop into squamous cell carcinoma. 
&nbsp;

The following factors increase the risk of pressure sore: 
&nbsp;

<ul>
	<li>Immobilization or paralysis (people who are bed-ridden after surgery or due to a medical condition)</li>
	<li>Age - Adults above the age of 70 are more susceptible</li>
	<li><a href="https://merisehat.pk/disease/obesity">Obesity</a></li>
	<li>Low body weight</li>
	<li>Poor blood circulation (e.g., due to vascular disease)</li>
	<li>Malnutrition, which may influence the condition of the skin</li>
	<li>Urinary or bowel incontinence</li>
	<li>Chronic diseases, such as <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes</a>, <a href="https://merisehat.pk/disease/atherosclerosis">atherosclerosis</a>, heart failure, kidney failure, <a href="https://merisehat.pk/disease/parkinsons-disease">Parkinson&rsquo;s disease</a>, and <a href="https://merisehat.pk/disease/multiple-sclerosis">multiple sclerosis</a>.</li>
	<li>Impaired sensation due to nerve damage</li>
	<li>Reduced mental awareness 
	&nbsp;</li>
</ul>

The following measures can help prevent pressure sores: 
&nbsp;

<ul>
	<li>Switching positions in bed at least once every two hours.</li>
	<li>In a wheelchair, sitting upright and straight and changing positions every 15 minutes.</li>
	<li>In hospitalized or immobilized patients, frequent examination of the skin for indications of pressure sores.</li>
	<li>Employing pillows or a pressure-relieving mattress to protect vulnerable areas from developing new sores.</li>
	<li>Wearing loose clothing.</li>
	<li>Using specific padding on pressure spots, such as the elbows and heels.</li>
	<li>Dietary adjustments to provide enough nutrition, potentially in conjunction with qualified dietitians.</li>
	<li>Staying hydrated.</li>
	<li>Exercising as much as possible, whether it&#39;s standing up and stretching or going for a few short daily walks. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>A pressure sore is an area of skin damage that develops due to prolonged and severe pressure on the skin.</li>
	<li>Pressure, friction, shear, and moisture, all contribute to the formation of pressure sores.</li>
	<li>Pressure sores can result in skin discoloration, swelling, red or warm skin, spongy or hard skin, pain, and itchiness of the affected area.</li>
	<li>They can occur anywhere but are most common on the skin overlying the bony areas of the body, such as the ankles, hips, tailbone, heels, and elbows. Pressure sores can also develop inside the mouth, especially due to intubation or ill-fitting dentures.</li>
	<li>If left untreated, pressure sores can result in cellulitis, osteomyelitis, and even sepsis.</li>
	<li>Pressure injuries are more likely to occur in those who are unable to prevent long-term uninterrupted pressure over bony prominences. If they don&#39;t actively alter positions or are assisted in doing so, they cannot defend themselves against the pressure.</li>
	<li>The best way to treat pressure injuries is to prevent them in the first place, which starts with a thorough medical and nursing history, a risk assessment, and a skin examination when the patient is admitted.</li>
	<li>Depending on the stage, pressure injuries can be treated in a variety of methods. The wound has to be cleaned, often with a saline solution.</li>
	<li>Debridement is occasionally required. This procedure removes dead tissue from the incision. Debridement is a critical step in the recovery process. It transforms the wound from one that is chronic and long-lasting to one that is acute and recent. 
	&nbsp;</li>
</ul>

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