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.
There are two types of pressure ulcer prevention: primary or secondary. Primary prevention aims to prevent the development of pressure sores in people who are at increased risk but who have never had one before. Its importance is essential in the event of hospitalization or a stay in a care establishment. Secondary prevention is intended for people who have already (had) bedsores. Indeed, these are exposed to an additional risk of formation of new lesions or aggravation of existing lesions. It is therefore a question of avoiding a relapse or a deterioration of their condition.
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.
Why is a care plan drawn up in advance?
Every situation is different; age, weight, nutritional status, help available, general condition and state of health all play a role. The presence of pressure sores is often not the only problem. Other conditions are usually involved, such as heart disease, diabetes, paralysis, dementia, etc. This is the reason why an individualized care plan is established in advance in order to determine the measures to be taken. Each care plan is the subject of a consultation meeting at the patient’s home or within the care establishment. This meeting brings together all the care providers (doctors, nurses, physiotherapists, informal caregivers, family, etc.) and the patient in person. The measures decided are recorded in a file and reassessed at regular intervals. Prevention of pressure ulcers therefore requires teamwork. The care plan can take the form of an electronic file or a notebook left at the patient’s home.
It is extremely important that all parties involved in this process know the risks and categories of pressure ulcers, as well as the actions to be taken in each situation. Support must therefore be uniform.
A risk assessment is always carried out on the occasion of the first contact. This assessment takes into account a series of factors such as age, degree of mobility, diseases present, nutritional status, skin sensitivity (often reduced in paralysis), the presence of continuous pressure in bedridden people, etc.
What are the main preventive measures?
Skin inspection
Anyone at risk for pressure ulcers is regularly subjected to a thorough skin inspection. Special attention is paid to pressure points such as the tailbone, hips and heels. Any sign of local redness, heat, swelling and hardness of the skin should be looked for with vigilance. People with dark skin tend to have a local purple color. The changes observed are recorded in the care plan so that other caregivers can also see them.
Change of position and pressure distribution
Prolonged pressure on the same areas should be avoided. This is why it is important to change your position regularly and to distribute the pressure as widely as possible. When changing position, the person is neither pushed nor pulled, but lifted. Any position can, if necessary, be maintained by means of specific devices. When using medical equipment such as probes, it must be ensured that this equipment does not exert any pressure.
It is not easy to predict in advance the best position or the best time to hold each position. But a good program can be established by trying out different positions, good follow-up and good communication.
A sitting Preferably involves a 90 ° flexion of the knees and hips. At the hip, an angle greater than 90 ° increases the pressure on the sit bones and should therefore be avoided. The feet rest on the floor or on an ottoman. In case of rear support, the legs are supported and the heels are left free. This position is also the best way to avoid bedsores in the heels. Make sure that the person always has everything they need to carry out their normal activities on hand. The possible / permitted duration of the sitting position differs from person to person. Adapt it according to the possibilities.
If the person is in lying position, make sure that the headboard is not raised more than 30 °. Otherwise, the person will slide down, causing additional pressure. It is recommended to alternate the supine position and the lateral, right and left positions, both at an angle of 30 °. The head, shoulders, back and pelvis are well supported by a specific device. 90 ° lateral positions should be avoided, as they transfer all the pressure to the shoulders and thighs. If the person is lying on their back, the head of the bed should be raised 30 ° and the knees should be bent 30 ° and supported.
There are different types of mattresses with pressure distribution, air circulation or alternating pressure, water or gel pads, ordinary or special covers. Their price varies from 100 to over 1,000 euros. There is no convincing evidence to support the superiority of one mattress over another. The choice will therefore depend on the patient’s condition, the help available, the possible need for cardiac massage, the possibility of properly disinfecting the mattress, the price, etc.
Food
A balanced diet, sufficiently rich in protein, fluids and calories, is extremely important. Weight and height are noted in the care plan, along with weight loss, changes in eating habits, and water and food intake. In case of problems, the advice of a dietitian can be useful.
Usefulness of massage?
Massaging the skin is not recommended, especially at bone protrusions. Topical products (such as moisturizer or skin protection cream) should be applied gently.
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