Pressure Ulcer Prevention

Introduction

Pressure ulcers can have a profound effect on an individual’s life causing pain and discomfort, and often resulting in the need for prolonged periods of bed rest. In addition pressure ulcers can be prone to infection, which in a few cases may prove to be fatal.

Pressure Ulcers

The European Pressure Ulcer Advisory Panel (EPUAP) (2009) [www.epuap.org] defines pressure ulcers as…

“A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with Shear”

In seating pressure ulcers are often seem at the ischial tuberocities or sacum. However, they can also develop where skin presses against wheelchair parts such as armrests, legrest stems and footplates. Pressure ulcers on other body parts, such as shoulder blades may result from laying in bed.

Common sites for pressure ulcers

Aeitiology of Pressure Ulcers

Pressure ulcers develop when tissue is squashed between a bony prominence and a supporting surface, causing capilaries to occlude (squash) preventing blood to deliver oxygen and other vital nutrients to the tissue.

Parallel forces in the tissue resulting, e.g. from sliding down in a wheelchair seat, also contribute towards pressure ulcer development. This strestching or tearing for can cause the skin layers to pull apart and/or capilaries to streatch, buckle or tear.

Pressure Ulcer Grades

EPUAP (2009) [www/EPUAP.org] defines pressure ulcers in 4 grades as follows…

Grade I

Intact skin with non-blanchable redness of a localized area usually over a bony prominence.“

Blanching means that when the red area is pressed, it turns temporarily white due to the occlusion of capillaries. It is important to note that red areas that do blanch is a natural reaction to pressure.

Grade II

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough…”

Grade II pressure ulcers may appear to look like broken blisters. A jagged wound over the sacrum is often observed in people who are exposed to shear forces from sliding down the seat or bed.

Grade III

“Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed”

Grade IV

Full thickness tissue loss with exposed bone, tendon or muscle.“

It is importnant to note that deep wounds can often start deep in to the tissue in the muscle layer, and so may not start as a lower grade of pressure ulcer.

Risk Factors

There are a large number of intrinsic and extrinsic risk factors that can affect an individua’ls liklihood of developing a pressure ulcer. Intrinsic risks are those risks that relate to an individual’s health condition. Anyone who has a physical impairment that limits their ability to move and/or their sensation are considered at risk of pressure ulcers. In addition any condition that can affects an individual’s circulation, e.g. heart condition; or reduce the condition of their skin, e.g. steroid based madication can also increase in individual’s risk of developing a pressure ulcer.

Extrinsic risks are factors outside of the body which include pressure, shear, poor posture, temperature and moisture. These factors are the factors that can be influenced by the use of appropriate support surfaces such as a special hospital mattress and seat/wheelchair cushion.