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A pressure sore is an "ischemic necrosis and ulceration of
tissues overlying a bony prominence that has been subjected to prolonged pressure against an external object (e.g., bed,
wheelchair, cast, splint)" (Merck Manual Online, 2001). Approximately 10% of hospital patients are afflicted with
pressure sores at any time (The National Decubitus Foundation, 2002).
The stages of pressure ulcers (decubiti) are:
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Stage
I: Skin is intact, erythematous (reddened), and does not blanch.
Skin may be firm or boggy, warm or cool to the touch, painful or
itchy. Indicators in darker skin are a dark red, blue or purple area;
warmth; edema; induration, or hardness.
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Stage
II: Superficial ulceration of the skin, appearing as an abrasion,
a blister, or a crater. Partial thickness skin loss (dermis or
epidermis, or both).
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Stage
III: A deep crater; full thickness loss of skin tissue, also
involving subcutaneous tissue down to the fascia.
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Stage
IV: Full thickness skin loss, with damage to bone, muscles,
tendons, or joint capsules. May involve sinus tracts.
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Nonobservable:
Covered with a dressing, an orthopedic device, eschar, or slough.
Cannot be visualized.
Risk factors for pressure sores are:
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Being bedfast or
chairfast, subject to pressure, friction, and shearing
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Advancing
age
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Being unable to position oneself
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Having decreased sensory perception
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Poor or decreased nutrition
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Moisture
The Braden Scale for Predicting Pressure
Sores is a tool for predicting pressure sores. It is available from: http://www.rohoinc.com/pdf/braden.pdf.
Assessment of a pressure sore includes its location,
stage, size, and surface appearance (granulation, necrotic, slough,
exudate). Look for sinus tracts and take a color photograph, if possible. The Nursing Outcomes Classification
(Johnson, Maas, & Moorhead, 2000, p. 427) provides a more detailed assessment and quantitative tool that includes skin
temperature, sensation, elasticity, hydration, pigmentation, perspiration, color, texture, thickness, lesion status,
perfusion, hair growth, and intactness. The nursing diagnosis for any altered epidermis or dermis is "Impaired Skin
Integrity." The PUSH tool, developed by the National Pressure Ulcer Advisory
Panel, is used to assess changes in pressure sores with treatment. A description of the tool is on
http://www.npuap.org/pushins.htm. A copy of the tool is on http://www.npuap.org/push3-0.htm.
Treatment of pressure sores begins by cleansing with normal
saline, using an irrigation device at 4 to 15 pound per square inch (National Guideline Clearinghouse, 1997).
Initially, the pressure sore appears to be getting larger with cleansing. Actually, you are removing nonviable tissue.
Debridement of pressure ulcers is done
through:
Dressings that absorb drainage include
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Hydrogel dressings, used to keep the wound wet and to absorb drainage. Examples include Tegagel and
NU-GEL.
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Absorptive dressings, such as Medipore and
Iodoflex.
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Alginates, fibers that come from seaweed and absorb drainage, such as AlgiCell and
AlgiDERM.
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Collagen dressings, such as BGC Matrix or
FIBRACOL, stop bleeding and aids healing.
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Foam dressings that absorb drainage, such as Reston and
BIOPATCH.
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Hydrocolloid dressings that absorb drainage. Common brands are Tegasorb and
NU-DERM.
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Enzyme preparations, such as Accuzyme or
Santyl. Enzymes act on collagen, protein, fibrin, elastin, and nucleoproteins.
Pressure ulcers are inevitably infected, usually with gram (-),
gram (+), and anaerobic bacteria. Treat with oral antibiotics, such as penicillin or
cephalosporins, or with antibiotic ointments, such as silver sulfadiazine or
triple antibiotic ointment.
Note that, among the many treatments available for pressure
sores, none has been demonstrated to be any more effective than any other (Bradley et al., 1999). Stage 4 pressure sores
require surgery, often with debridement to the bones.
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Pressure Sore Facts & Hints
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The stages of pressure sores were revised a few years ago to include assessment of people with dark skin color.
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Iatrogenic Pseudomona infections are common in pressure sores with occlusive dressings.
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Excessive moisture in and around the wound can lead to maceration and further skin breakdown.
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The best treatment for pressure sores is prevention. This means turning a person who is confined to a bed at least every two hours, to relieve pressure over bony prominences.
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Many products are available to keep pressure off bony prominence, such as alternating pressure mattresses, eggcrate mattresses, water beds, silicone gel beds, air floatation mattresses, or Stryker frames (for people with spinal injuries). Remember that none of these is a substitute for frequent turning.
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Friction and "shear" also cause pressure sores. To prevent damage from friction and shear, avoid leaving the person rolled up in bed, avoid rubbing the person across the sheets, and use minimum turning sheets and incontinence pads.
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Help the wheelchair-bound person to shift his or her weight periodically to prevent pressure sores.
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References/Bibliography for articles
1.
Bradley, M., Cullum, N., Nelson, E.A., Petticrew, M., Sheldon, T., &
Torgerson, D. (1999). Systematic reviews of wound care
management:
(2) Dressings and topical agents used in the healing of chronic wounds.
Health Technology Assessment, 3(17,
Part2), 1-135.
2.
Johnson, M., Maas, M., & Moorhead, S. (2000). Nursing Outcomes
Classification (NOC) (2nd. Ed.). St. Louis: Mosby.
3.
Merck Manual Online. (2001). Pressure Sores.
Retrieved March 11,
2002.
http://www.merck.com/pubs/mmanual/section10/chapter122/122a.htm.
4.
The National Decubitus Foundation.
(2002). Cost savings through
bedsore avoidance. Retrieved March 11, 2002.
http://www.decubitus.org/cost/cost.html
5.
Wound Ostomy and Continence Society. (2001). OASIS Guidance
Document. Retrieved March 11, 2002.
http://www.wocn.org/PDF/WOCNOASISGuidance.pdf.
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Pressure Sore Care
Websites
To explore the latest on pressure sore care, check out these
websites:
National Pressure Ulcer Advisory Panel
(NPUAP)
http://www.npuap.org/Default.htm
Current research, newsletter, conferences, and information about
pressure ulcers
Sepsis
Bed Sore Pressure Ulcer - Learn more about bed sores, pressure
sores, sepsis, decubitus ulcers, and pressure ulcers. Click here to
find out more about nursing home abuse and your legal rights.
The National Decubitus Foundation
http://www.decubitus.org
Describes the great enigma of wound care: Medicare will
not pay for their prevention, but will pay for special beds after a Stage III ulcer has developed.
Wound Care Information Network
http://www.medialedu.com/default.htm
Site maintained by two MDs: A. Freedline and T. Fishman;
information based on National Guidelines
The Wound Care Society, from the UK
http://www.woundcaresociety.org/
Information about membership; clinical information available
for purchase
Wound,
Ostomy, and Continence Nurses Society
http://www.wocn.org/
Offers conferences, fact sheets, publications; focus is on
ostomy care but check out the "WOCN Guidance on Oasis Skin and Wound Status M0 Items."
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