Pressure Ulcers: Prevention and Treatment
Stewart R. Carter
Sewit Amde
Fred A. Luchette
I. EPIDEMIOLOGY
A. In an acute care setting, the incidence of pressure sores ranges from 7% to 9% with an associated prevalence between 14% and 17%.
B. Residents in chronic care facilities, such as those with spinal cord injuries and patients in the intensive care units (ICUs), are at the highest risk for the development of pressure sores.
C. The development of pressure ulcers in the ICU results in increases in length of stay, morbidity, mortality, and associated health care costs.
II. PATHOPHYSIOLOGY
A. Pressure sores form as the end result of unrelieved pressure exerted on tissue overlying bony prominences; approximately 80% develop over the sacrum, coccyx, femoral trochanters, ischial tuberosities, lateral malleoli, and heels.
B. Normal arterial capillary blood pressure is critically low when external pressures are >32 mm Hg. Tissues overlying bony prominences are subject to this critical pressure while a patient is in the supine position.
C. Prolonged exposure to ischemia results in tissue necrosis; differing tissues exhibit different sensitivities to ischemia.
1. Muscle has much poorer tolerance to pressure than does skin or subcutaneous tissue.
2. Muscle and subcutaneous tissue infarction without skin necrosis is the “tip of the iceberg” phenomenon.
3. Studies have shown that ischemic necrosis can be prevented with intermittent restoration of blood flow.
D. Risk factors associated with pressure ulcer formation in ICU patients include tissue hypoxia, hypotension, excessive moisture or perspiration, hyper-/hypothermia, malnutrition, impaired mobility and sensation, the presence of positioning devices such as restraints, braces, vests, or fixation devices, and fecal or urinary incontinence. Unrelieved pressure associated with naso- and orogastric tubes and endotracheal tubes is also a risk factor.
III. PREVENTION
A. Prevention of pressure sores begins with education and dedicated care.
1. Institutions should have structured risk assessment policies and practice to identify vulnerable patient populations; risk assessment should be conducted on admission and repeated as necessary, particularly when acuity increases.
2. Skin assessment and routine care should be performed to identify early signs of pressure damage; avoid massaging, friction, and turning onto body surfaces with erythema from previous episodes of pressure loading.
