Coursename
Pressure ulcers are damaged areas of the skin, which develop due to the long-term effect of pressure or friction in the areas where the bone is close to the skin, such as heels, sacrum, ischial tuberosity, lateral malleoli and greater trochanters. The epidemiology of pressure ulcers proves that today, despite the profound understanding of them, pressure ulcers are still a serious global health care problem, which affects millions of people worldwide. For example, in the US every year more than 2.5 million people suffer from the pressure ulcers (Cuddigan, Berlowitz, and Ayello 208-215). In 2013 pressure ulcers caused 29000 deaths in all countries (Naghavi et al. 117-171). Pressure ulcers are associated with elderly patients and they more often affect patients of the intensive care departments due to the prolonged stay in one position and an overall weakening of the organism because of the primary disorder. Such numbers indicate the actuality of the problem and the understanding of its physiology is the only way to solve it.
There are three main groups of factors, which contribute to the development of the pressure ulcers. External factors include the hard surface of the bed or chair, long waiting time before admission to the hospital, and immobilization of the extremity due to the friction (Russell 1084-1100). Extrinsic factors arise from the environment and are decisive. These factors include local pressure, friction, shear and effects of the excessive moisture on the skin. Local pressure causes impaired blood flow in the area of future ulcer, which leads to ischemia, hypoxia, and inflammation. Friction contributes to the development of the pressure ulcers by damaging the superficial layers of the skin, reducing its barrier function and facilitating the occurrence of the infection. Another mechanism of the pressure ulcers development is shear. When patients' skin adheres to the bed it remains fixed to it during the body movement thus leading to the damage of the skin, which also promotes the pressure ulcers. Excessive moisture can promote the occurrence of the ulcers in different ways. It can be enuresis, excessive perspiration or the accumulation of inflammatory exudate in the area of the ulcer. All these factors increase the quantity of microorganisms on the skin of the patient, including pathogenic ones, which promote the damage of the skin dealt with the pressure. The other big group of factors which increase the risk of pressure ulcer development is intrinsic factors. It is a huge group of the specific characteristics of the organism that make it more prone to pressure ulcers. Intrinsic factors can also be divided into four smaller groups. Impaired mobility is probably the most important group. It may develop due to the various reasons such as fractures, neuromuscular disorders, postoperative status, coma, paralysis or loss of extremities. All these reasons are very different but their main similarity is crucial in the pathophysiology of the pressure ulcers: they always interrupt the normal level of person’s mobility and force patients to spend a lot of time in unnatural body position. Next group of intrinsic factors includes those which are associated with the inadequate nutrition. This applies not only to inadequate intake of proteins, fats, and carbohydrates. Dehydration also increases the risk of pressure ulcers. Reduction of the teeth number and impairment of the taste and smell are other causes which indirectly decrease the amount of food consumed by elderly people thus leading to the malnutrition. Another group of factors includes multiple comorbidities, which can negatively impact the pathogenesis of the pressure ulcers. For example, atherosclerosis and diabetes mellitus cause circulatory disorders of the skin. Diabetes leads to the development of the diabetic angiopathy, which leads to the disruption of the circulation through the arteries. Atherosclerosis leads to the cholesterol accumulation in the vascular intima which also leads to circulation impairment. As patients with diabetes and atherosclerosis already have impaired circulation pressure ulcers on their skin develop faster and require less pressure. Congestive heart failure, COPD, malignancies and chronic renal disease also burden the pressure ulcers. Reduced pain sensation of the skin can also facilitate the development of the pressure ulcers because the patient may not notice any discomfort when necrosis of the skin occurs. Alcohol intoxication can also provoke the pressure ulcers because of its features. When a person with alcohol intoxication sleeps, significantly fewer movements are being made, compared to the healthy man. Therefore, longer remaining in the same position contributes to the development of ulcers in the critical areas. Finally, the last group of intrinsic factors includes the features of the aging skin. Skin of the elderly people loses its elasticity and the blood flow through it becomes less voluminous. In the same time happens the change of the dermal pH and loss of subcutaneous fat, which also contributes to the increased risk of pressure ulcers. Immunocompromised patients are also at greater risk of developing a pressure ulcer.
Sometimes the early diagnosis of the pressure ulcer is not an easy task. It can look similar to many other skin diseases. But the beginning of treatment in early stages provides the best health outcomes for the patients. Therefore, medical personnel needs standardized algorithms that help detect this condition as early as possible. The Braden Scale is the most common tool used to prevent pressure ulcers and assess the risk of their occurrence in a patient (Pancorbo-Hidalgo et al. 94-110). It consists of six numbers which are given depending on the condition of the patient's sensory perception, exposure to the moisture, patients mobility and activity, nutrition, friction and shear of the skin. If the total point is nine or less than the patient is at very high risk of pressure ulcers development. Medical personnel should be able to evaluate and interpret patients’ status in order to provide adequate and timely treatment for patients with pressure ulcers.
Pathophysiology of the pressure ulcers can be understood better with the knowledge of the stages of this pathology. As it was said above, the main cause of the disease is prolonged pressure on the skin. It disrupts normal blood flow in the affected area and causes ischemia of the tissues. Ischemia in its turn may cause necrosis of the damaged tissues - a basis on which develops an ulcer. Depending on the depth of the skin lesions and affection of other tissues pressure ulcers are classified according to the NPUAP system into six groups. First stage ulcer looks like an erythematous but visually not damaged skin. It appears in the typical areas of pressure ulcers. The patient may feel discomfort in the affected area. It may be a pain, high local temperature or conversely - the low temperature of the affected area. Paleness and stiffness of the affected area often precede the first stage of the pressure ulcer. The first stage is often hard to be diagnosed, especially in the patients with the dark skin. An additional sign which points at the pressure ulcer is that the erythema is not-blanchable, which means that it does not lighten under pressure. It is a sign of the inflammatory origin of the erythema (Bluestein and Javaheri 1186-94). Every patient with suspicious erythema localized in the typical pressure ulcers area should be evaluated on a Braden Scale to begin treatment as soon as possible and prevent further disease progression. Second stage ulcer appears as a partial loss of dermis. It can be described as a shallow ulcer with the red bottom but without slough. The second stage also includes blisters, which can be intact and filled with serum or damaged. In addition, second stage ulcer does not have to bruise around because it points at the possible deep tissue injury. In this stage happens necrosis of both epidermis and dermis. Therefore, the integrity of the skin is disrupted, unlikely to the first stage. In the third stage, necrosis penetrates the dermis and reaches subcutaneous tissue. In this stage in the ulcer can be visible subcutaneous fat but not muscle, bone or tendons. The depth of the ulcer may vary due to the different amount of the subcutaneous fat in different body areas. Therefore it may appear shallow or be very deep in some locations. Slough can cover the bottom of the ulcer. Also, third stage ulcers have one feature: in the depth, they become wider than the skin lesion on the surface of the ulcer. It helps to distinguish third and second stage ulcers in hard cases. Fourth stage ulcers are very similar in their appearance to the third stage but they include muscle, bone, or tendon tissue which can be palpable and seen directly. Exposure of bones may cause secondary osteomyelitis. A big area of inflammation and depth of the necrosis can lead to the systemic infection and cause sepsis. When the base of the ulcer is covered with slough or necrotic masses which make impossible to throughout inspect the bottom of the wound and to estimate the severity of the injury and classify the ulcer, then the ulcer should be classified as a unstageable ulcer with the unknown depth. In this case, the stage should be determined after the primary surgical treatment of the wound (Bluestein and Javaheri 1186-94). The other specific type of damage, associated with pressure ulcers is deep tissue injury. In the case of this disorder, superficial skin layers remain relatively intact, but in the area of injury is present a blister and the skin can change the color, which makes it harder to diagnose this condition in the people with dark skin.
As it was said before, the understanding of the pathogenesis and pathophysiology of the pressure ulcers is crucial for their successful management. While most of the patients acquire the pressure ulcers in the medical facilities during the treatment of other conditions, bedsore can greatly burden the primary disease and can be very hard to manage. Therefore, pressure ulcers are easier to prevent than to treat. especially in the case of third or fourth stage pressure ulcers. Very often the rate of pressure sores in the medical facility tells about the quality of the care, which are received in that facility. Preventive measures should be pointed at the most at-risk patients and include pressure-reducing beds. These beds are constructed to avoid excessive and prolonged pressure on certain parts of the body. They can function actively, for example by alternately inflating certain parts of the mattress or just have a mattress on a specific material that prevents pressure. Patients should be regularly washed and their skin humidity should be frequently monitored as well as the visual appearance of the critical areas of the skin. Medical personnel should be trained very well to carry out prophylactic measures and perform them according to the protocol. The treatment of the pressure ulcers includes a combination of pharmacological therapy and surgical treatment. The basis of pharmacological therapy of pressure ulcers is antibiotics and antiseptic medications, which are used to prevent infectious complications of the pressure ulcers. Surgical treatment is often required when the ulcer is deep or when it affects the big area. The aims of pressure ulcers surgical treatment is to remove dead tissues from the ulcer, to prevent their contagion and to provide the best conditions to heal the wound. Septic complications require a combination of surgical treatment, antibacterial therapy and infusion therapy to prevent the patient from the shock. Today pressure ulcers are still a great problem, especially in the critical care units. I think that this problem cannot be completely solved until we don’t have the treatment of the old age. However, with the proper care and careful monitoring, it can be minimized.
Works cited:
Bluestein, D and A Javaheri. "Pressure Ulcers: Prevention, Evaluation, And Management". Am Fam Physician 78.10 (2008): 1186-94. Print.
Cuddigan, Janet, Dan Berlowitz, and Elizabeth Ayello. "PRESSURE ULCERS IN AMERICA: Prevalence, Incidence, And Implications For The Future". Advances in Skin & Wound Care 14 (2001): 208-215. Web. 25 June 2016.
Naghavi, Mohsen and Haidong Wang. "Global, Regional, And National Age–Sex Specific All-Cause And Cause-Specific Mortality For 240 Causes Of Death, 1990–2013: A Systematic Analysis For The Global Burden Of Disease Study 2013". The Lancet 385.9963 (2015): 117-171. Web. 25 June 2016.
Pancorbo-Hidalgo, Pedro L. et al. "Risk Assessment Scales For Pressure Ulcer Prevention: A Systematic Review". J Adv Nurs 54.1 (2006): 94-110. Web.
Russell, Linda. "Physiology Of The Skin And Prevention Of Pressure Sores". British Journal of Nursing 7.18 (1998): 1084-1100. Web.
