Pressure Sores

Synonyms: pressure ulcers, bed sores, decubitus ulcers

Pressure sores may present as persistently red, blistered, broken or necrotic skin and may extend to underlying structures, e.g. muscle and bone. A pressure ulcer may be caused by pressure, shear, friction or a combination of these.¹

Risk factors

• Increasing age
• Severely ill
• Vascular disease
• Neurologically compromised, e.g. those individuals with spinal cord injuries, stroke or receiving epidural analgesia
• Impaired mobility, especially wheelchair users
• Impaired nutrition
• Obesity
• Poor posture or use equipment such as seating or beds which do not provide appropriate pressure relief

Risk assessment²

• Risk assessment tools should only be used as an aide memoir and should not replace clinical judgment.³
• Commonly used assessment scales include the Norton, Braden, and Waterlow scales. The Braden risk assessment is considered by many to be the most valid and reliable scoring system for a wide age range of patients.⁴

Pressure ulcers can develop in any area of the body. In adults damage usually occurs over bony prominences, such as the sacrum. Patients with pressure ulcers should receive an initial and on-going assessment which should include:

• Health status: illness, nutrition, pain, continence, neurological (sensory impairment, level of consciousness, cognitive status), blood supply, mobility, posture, signs of local or systemic infection, medication
• Previous pressure damage
• Psychological and social factors
• Ulcer assessment: should be supported by photography (calibrated with a ruler) and tracings. Ulcer assessment should include:
  • Cause of ulcer
  • Site/location
  • Dimensions of ulcer
  • Stage or grade
  • Exudate amount and type
  • Local signs of infection
  • Pain
  • Wound appearance
  • Surrounding skin
  • Undermining/tracking (sinus or fistula)
  • Odour

Reassessment of the ulcer should be performed at least weekly but may be required more frequently.

• Repositioning of the patient.
• Treatment of concurrent conditions which may delay healing.
• Pressure relieving support surfaces such as beds, mattresses, overlays or cushions.
• Local wound management using modern or advanced wound dressings and other technologies.
• Patients with identified grade I pressure ulcers are at a significant risk of developing more severe ulcers and should receive interventions to prevent deterioration.
• Pain relief:
  • Pain is often significant and disabling for those with pressure ulcers.
  • Paracetamol may be sufficient, but patients often require stronger analgesia.
  • Non-steroidal anti-inflammatory drugs may increase peripheral oedema and are inappropriate for patients with pressure ulcers.
  • Patients may require referral to a pain clinic.
• Infection control:
  • Reduce risk of infection and enhance wound healing by hand washing, wound cleansing and debridement. Protect from exogenous sources of contamination, e.g. faeces.⁶
  • If purulent material or foul odour is present, more frequent cleansing and possibly debridement are required.
  • When there are clinical signs of infection which do not respond to treatment, radiological examination should be undertaken to exclude osteomyelitis and joint infection.⁶
  • Systemic antibiotics are required for patients with bacteraemia, sepsis, advancing cellulitis or osteomyelitis.⁶
• Nutritional support should be given to patients with an identified nutritional deficiency.
• Adjunct therapies Include electrotherapy and low laser irradiation. There is currently insufficient research to recommend their general use.⁶

Mobility and positioning

• All patients with pressure ulcers should actively mobilise, change their position or be re-positioned frequently.
• Passive movements should be considered for patients with pressure ulcers who have compromised mobility.
• Avoid positioning individuals directly on pressure ulcers or bony prominences.

Pressure relief

• Pressure relieving equipment, e.g. alternating pressure systems, redistributes the load or relieves the pressure at regular intervals. Pressure reducing equipment redistributes pressure by spreading the weight over a larger surface area, e.g. mattresses, cushions and dynamic air loss systems.
• Patients with pressure ulcers should have access to appropriate pressure relieving support surfaces 24 hours a day and this applies to all support surfaces.¹
• Current consensus recommends that:¹
  • All individuals assessed as having a Grade 1-2 pressure ulcer should be placed on a high specification foam mattress or cushion with pressure-reducing properties combined with close observation of skin changes and a documented positioning and repositioning regime.
  • If there is any perceived or actual deterioration of affected areas or further pressure ulcer development an alternating pressure mattress (replacement or overlay) or sophisticated continuous low pressure system (e.g. low air loss, air fluidised, air floatation, viscous fluid) should be used.
  • Depending on location of ulcer, individuals assessed as having Grade 3-4 pressure ulcer (including intact eschar where depth cannot be assessed) should be placed on an alternating pressure mattress or sophisticated continuous low pressure system.
  • If alternating pressure equipment is required the first choice should usually be an overlay system.

Dressings and topical agents

• There is no conclusive research evidence to guide clinicians decision making about which dressings are most effective in pressure ulcer management.
• However professional consensus recommends that modern dressings (e.g. hydrocolloids, hydrogels, foams, films, alginates, soft silicones) should be used in preference to basic dressing types, e.g. gauze, paraffin gauze and simple dressing pads.¹

• Pressure ulcers are often slow to heal, because of continued adverse factors such as pressure or poor nutrition.
• May spread to deep tissues and also cause localised infection, including osteomyelitis, and systemic infection.
• The presence of pressure sores is associated with a twofold to fourfold increased risk of death, but this is because pressure sores are a marker for underlying disease severity and other co-morbidities.⁷

• Skin injury due to friction and shear forces should be minimised through correct positioning, transferring and repositioning techniques.
• Eliminate any source of excess moisture due to incontinence, perspiration or wound drainage.
• Reduce underlying risk factors such as poor nutrition.
• Education and training, e.g. mobility, positioning, skin care, use of equipment, for patients and their carers.