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What is it about ?
A pressure sore is a localized lesion of the skin and / or underlying tissues (dermis, fat, muscles, bones) caused by pressure or friction. It mainly forms in places where there is little tissue between the bone and the skin, such as the heels, tailbone or side of the hips.
Pressure ulcers are classified according to their severity into 4 categories:
- Category I: local redness, which does not disappear on pressure. The skin is still intact.
- Category II: formation of blisters filled with liquid or peeling of the epidermis; the skin breaks away from the underlying tissue.
- Category III: the skin is locally damaged down to the dermis. This usually results in a red sore, possibly covered with a dry scab.
- Category IV: presence of significant tissue damage, including in the dermis. A crater forms, which may be covered with pus, necrotic tissue and black scabs; the depth of the wound is difficult to estimate.
What is their frequency?
In Belgium, 12.1% of people who stay in hospital develop bedsores. We do not have exact figures for nursing and care homes, but in neighboring countries pressure sores affect 6.4% to 31.4% of residents.
What is the treatment of pressure ulcers?
Developing a care plan
Treatment of pressure ulcers requires teamwork. This means that doctors, home nurses, physiotherapist, dietitian, family members and informal caregivers must all work together to achieve a good result. This is why the start of treatment is preceded by consultation with the patient, with a view to establishing an individualized care plan adapted to their specific needs.
An important first step in developing a plan of care is to assess pressure ulcers. Several factors are taken into account in this assessment:
- the person’s state of health: certain diseases can play a role in the appearance of pressure sores, such as diabetes, paralysis, vascular affections,excess weight or insufficient weight, …;
- the characteristics of the pressure ulcer: severity, local blood circulation, sensitivity disorders (absence of sensation, pain), signs of infection, progress of the wound, dimensions;
- risk factors for new pressure ulcers;
- nutritional status, degree of mobility (is the person able to move, to move?), psychic state;
- the person’s wishes: they must always have a say.
Assessment of the lesion
The lesion assessment takes into account all of the above factors. A report of this assessment will describe the cause, location, date of onset, dimensions, depth, presence of necrotic tissue, appearance, odor, amount of fluid, course, signs of infection, the appearance of the skin around the lesion, pain, etc. This report is attached to the file. Changes are noted after each wound care session.
All caregivers agree to perform the assessment in the same way (e.g. measuring the length, width and depth of the wound, estimating the amount of fluid production using bandages, describing standardized fabric color (red, yellow, black). Once a week, it may be helpful to take a photo of the lesion. This facilitates communication regarding the wound.
Undernutrition slows down the healing process. During the assessment, special attention is therefore also given to the nutritional status and eating habits of the person. This part of the assessment will ideally be carried out by a dietitian. The height and the weight, the evolution of the weight, the quantity of food and drink consumed are noted in the file. If necessary, the dietitian can provide targeted advice on the composition of the diet and any dietary supplements (for example, a sufficient intake of protein).
Treatment of pressure ulcers
The main goal of treatment is to prevent both the extension of existing bedsores and the appearance of new wounds. This is done by using devices that reduce the pressure or the duration of the pressure on the lesions, or that distribute the pressure over a larger area. Two methods can be applied: the use of special mattresses and the change of positions.
There are different types of pressure distributing mattresses, for example with air circulation or alternating pressure. There is no evidence to support the superiority of one system over the other. The choice will rather depend on the patient’s situation: his state of health, the nature, number and size of the lesions, living conditions, cost, etc.
The change of position implies that the person alternates between the different positions at regular intervals (for example every 2 hours): lying on the back – lying on the left side – lying on the right side. If there is no improvement, consider using other devices.
Necrotic tissue in and around the wound can interfere with healing and must therefore be excised. This procedure is called “debridement”. Debridement can be done through surgery or by applying ointments containing enzymes, which break down necrotic tissue.
Much research has been carried out in recent years on the use of topical products and special dressings. These products and dressings aim to create the most favorable environment for healing wounds. There is no evidence to support the superiority of one product over another. It does not matter, therefore, the local treatment which is instituted. If this treatment gives a result, it can be continued as is. Otherwise (no improvement or worsening of the wound), it is preferable to try another type of product and / or dressing.
In principle, surgical treatment is reserved for cases where other treatments have failed. The choice may be a debridement or a large cut of the lesion, followed by local treatment. Sometimes he is opted for a skin graft.
In the presence of signs of infection, a course of antibiotics may be considered.
As for other treatments, such as electrical stimulation, UV exposure, laser, hyperbaric oxygen, or negative pressure, there is no convincing evidence that they are effective.
In the presence of a single pressure ulcer in the heel, it is advisable to completely release the pressure on the heel. To do this, a support device can be slipped under the calf, with the knee slightly bent, so that the heel is not in contact with the ground.
Sources
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