Brief overview
- Treatment: Good skin care and regular pressure relief (positioning, aids), for wounds: moist wound dressings, regular cleaning, in case of advanced degree possibly surgery
- Symptoms: redness, water retention, later pressure sores with pain, in case of infection sometimes also with fever, chills, putrid odor, later dead black tissue areas (necroses), complications such as blood poisoning or bone inflammation possible
- Diagnosis: visual diagnosis, finger test, history of risk factors, possibly blood test, tissue samples (smear), in higher severity ultrasound, X-ray, computed tomography (CT), magnetic resonance imaging (MRI)
- Causes: Sustained, severe pressure leading to undersupply of affected tissue, gradual destruction of skin, tissue and bone; various risk factors such as prolonged sitting or lying, sensitive skin condition, humidity, diabetes.
- Course and prognosis: prevention is important, early treatment is elementary, as the healing process is protracted even with optimal treatment, increased risk of recurrence after successfully treated pressure ulcers, the majority of pressure ulcers are superficial wounds, mortality is increased in severe cases.
What is pressure ulcer?
A pressure ulcer (decubitus, decubital ulcer) is a localized damage of the skin, the underlying tissue and in extreme cases also of the bone. It manifests itself in the form of a permanently open wound of varying depth, especially on parts of the body close to the bone, such as the buttocks, coccyx or heels.
People who are immobile or bedridden, for example in hospital, are particularly affected. Wheelchair users also have an increased risk of pressure sores, especially in the buttock area.
What are the degrees of pressure ulcers?
A pressure sore changes the skin. Depending on how severe the changes are, doctors and nurses distinguish between different degrees of severity:
- Decubitus grade 1: In the initial phase, the affected skin area reddens and sharply demarcates itself from its surroundings. The redness persists even when pressure is relieved. The area may be hardened and warmer than the surrounding skin. Basically, however, the skin is still intact.
- Decubitus grade 2: In decubitus grade two, blisters have formed on the skin. Sometimes the top layer of skin is already detached. An open wound develops, but it is still superficial.
- Decubitus grade 3: In decubitus grade three, the pressure ulcer extends to the muscles under the skin. A deep, open ulcer is seen. Under the healthy skin at the edge of the pressure ulcer, there are sometimes “pockets” that extend from the ulcer.
Severity levels one to four are also found synonymously as “stage one to four” in many specifications.
What aids are available for pressure ulcers?
The earlier pressure sores are detected, the better they can be treated. Basically, the therapy is divided into two areas: local and causal therapy. Local therapy is a local treatment of the pressure ulcer with medical means, whereas causal therapy focuses on eliminating the causes of the pressure ulcer.
Pressure ulcer local therapy
Local therapy aims to care for the pressure ulcer and help it heal. In the case of a first-degree pressure ulcer, it is usually sufficient to carefully care for the affected skin area and relieve it of pressure. These are the same measures that are used for prevention.
Sometimes technical procedures such as the vacuum sealing method or negative pressure wound therapy are used as part of the local therapy.
Pressure ulcer causal therapy
Successful pressure ulcer treatment depends on eliminating the cause: the pressure. For patients lying down, for example, a special pressure ulcer mattress or bed is recommended. In addition, regular repositioning of the patient is important. For wheelchair users, seat cushions are advisable.
There are certain aids that reduce pressure on vulnerable skin areas by distributing it more evenly. The following systems have proven effective:
- Soft positioning systems such as foam mattresses, gel pads or air cushions distribute the body weight and thus the pressure over a larger area.
- Micro-stimulation systems (MiS) encourage the patient’s own small movements. This stimulates blood circulation in the tissue, which prevents pressure ulcers or supports the healing of existing ulcers.
The use of sheepskins, water mattresses, seat rings, fur slippers and absorbent cotton bandages as aids in pressure ulcer positioning is no longer recommended.
There are also restrictions on soft bedding systems, as these lead to slowed fine motor skills in some sufferers. In addition, alternating pressure mattresses are not advisable for certain patients (including pain or stroke patients with perceptual disorders). In addition, they may increase muscle tension and disturb the patient’s night’s rest due to their loudness.
Special anti-decubitus seat cushions are suitable for wheelchair users. These reduce the pressure on the buttocks.
Painkillers help against the pain associated with pressure sores. In addition, special movement exercises promote blood circulation and prevent the patient from always lying on the same spot.
Causal therapy also includes the effective treatment of concomitant diseases, including those of a psychological nature. Depression, for example, sometimes prevents the success of treatment.
Pressure ulcer: Surgery
Pressure ulcers of grades one to three usually do not require surgical treatment. The situation is different, however, for pressure ulcers of grade four: here, surgical intervention is almost always necessary. In this case, the surgeon removes the pressure ulcer during an operation. Sometimes it is also necessary to remove part of the bone.
In very large pressure ulcers, plastic surgery is sometimes necessary. Then the surgeon grafts skin and soft tissue from other parts of the body onto the destroyed part of the body.
How can you recognize a pressure sore?
Symptoms of a pressure sore are generally skin changes. At the beginning, redness and water retention (edema) appear on the affected parts of the body, later more severe skin damage develops. Doctors refer to these as ulcers, which are usually open and painful wounds.
Under certain circumstances, an unpleasant (foul) odor develops in the case of bacterial colonization. The infection causes symptoms such as fever and chills.
In the later stages, the tissue dies and is sometimes visible on the wound by dark or black spots. What is not visible is what is damaged in the deeper tissue. In some cases, abscesses or fistulas form, and bone inflammation is also possible.
Where pressure sores form particularly easily
In the supine position, pressure sores most frequently occur on the buttocks, above the coccyx and on the heels. In the lateral position, the rolling hills of the thighs and the ankles are usually affected. Rarely, pressure ulcers develop on the ears, back of the head, shoulder blades or toes.
Generally, pressure ulcers form less frequently in the lateral or prone position. An exception is prolonged surgery in the prone position, when pressure ulcers sometimes develop on the knees, face (forehead and chin), toes, or pubic bone.
Pressure ulcer: complications
A pressure ulcer needs quick treatment, otherwise it spreads to deeper tissue layers. The tissue then dies in some cases (necrosis). This makes surgical removal necessary.
In the supine position, pressure sores most frequently occur on the buttocks, above the coccyx and on the heels. In the lateral position, the rolling hills of the thighs and the ankles are usually affected. Rarely, pressure ulcers develop on the ears, back of the head, shoulder blades or toes.
Generally, pressure ulcers form less frequently in the lateral or prone position. An exception is prolonged surgery in the prone position, when pressure ulcers sometimes develop on the knees, face (forehead and chin), toes, or pubic bone.
Pressure ulcer: complications
A pressure ulcer needs quick treatment, otherwise it spreads to deeper tissue layers. The tissue then dies in some cases (necrosis). This makes surgical removal necessary.
The hyperacidity of the tissue causes the arterial blood vessels to dilate, thus increasing the blood supply to the tissue. This is visible in the reddening of the skin. The dilated vessels release fluid and proteins into the adjacent tissue, resulting in water retention (edema) and blisters. The tissue destruction increases more and more – a decubitus has developed.
Pressure ulcer: risk factors
Various factors promote the development of pressure sores:
- Prolonged lying or sitting: Pressure sores develop primarily in people who lie or sit more or less motionless for long periods of time. Pressure ulcers often occur in elderly patients who are bedridden due to an acute or chronic illness. Patients in wheelchairs also belong to the risk group.
- Diabetes: Diabetes damages the nerves over time, so that people with diabetes sometimes no longer perceive touch, pressure and pain as well. They register increased pressure on skin and tissue with a corresponding delay.
- Reduced sensitivity to pain
- Low body fat
- Incontinence: Leads to moist skin at the anus or vagina, for example. The skin softens, which promotes pressure ulcers.
- Certain medications: For example, painkillers
- Excess weight: Increases pressure on skin and tissue when lying or sitting.
- Lack of care: lying for long periods in damp and soiled incontinence pads or pants softens the skin, causing irritation and thus promoting pressure ulcers.
- Malnutrition/undernourishment: It dries out the skin. In addition, those affected lack fat deposits that cushion pressure. Both of these factors pave the way for pressure ulcers.
- Pre-existing skin diseases and irritations
How is a pressure ulcer diagnosed?
Especially for people who are cared for at home, as well as for their relatives, knowledge about the risk of pressure sores is essential. Here, too, a careful and regular skin inspection is mandatory.
In hospitals and nursing homes, nursing staff take care of this important task. As a rule, nursing staff document the condition of the skin on admission and at regular intervals thereafter. They also record the risk factors and the individual risk status for pressure ulcers. This serves as the basis for pressure ulcer prophylaxis.
Finger test
If the skin is intact, the doctor or nurse usually performs the finger test. This can be used to identify a pressure sore at an early stage. To do this, the person treating the patient presses his or her finger on the already reddened, suspicious area of the patient’s skin. If the skin is not clearly paler immediately after release and remains reddened, the finger test is positive. In such a case, a pressure ulcer stage one is already present.
Swab, blood test, X-ray
If a pressure sore is already present as an open wound, the physician orders further examinations. These can be used to assess the extent of the pressure sore and initiate the necessary treatment.
In addition, the doctor takes a blood sample if an infection of the pressure sore is suspected. In the laboratory, inflammation values can be read and in some cases pathogens can be detected in the blood.
If the pressure ulcer is far advanced, imaging examination procedures are also used. To assess tissue damage, doctors sometimes perform an ultrasound. X-rays, computed tomography (CT) or magnetic resonance imaging (MRI) can be used to determine whether the pressure ulcer has already penetrated the bone or whether fistulas (connecting duct into a hollow organ) are present.
How can pressure sores be prevented?
Physicians and nursing staff regularly assess the individual pressure ulcer risk of each patient. For this purpose, they use documentation forms, for example the so-called Braden scale.
Based on the results, doctors and nurses draw up an individual plan of action for pressure ulcer prophylaxis or prevention. These measures include, for example:
Positioning and mobilization
For bedridden or immobile patients, it is important to change the lying position regularly – even if the patients are lying on an anti-decubitus mattress. Caregivers use various positioning techniques and aids for this purpose. Positioning involves completely relieving pressure or exposing particularly vulnerable areas, such as the heels.
In addition, the mobilization of patients with the aid of targeted movement exercises plays a central role. Depending on the patient’s physical ability, these exercises can be performed by the patient himself or passively with the support of a physiotherapist or nurse.
Skin care
In addition, regular skin monitoring and careful skin care are important. The latter keeps the skin healthy and thus reduces the risk of pressure sores. With regard to pressure ulcer prophylaxis, proper skin care means:
- Washing the skin with water that is as cool as possible, since excessively warm water dries out the skin.
- Avoid washing additives as far as possible or prefer liquid, pH-neutral substances.
- In the case of very dry and brittle skin, use oil bath additives
- Use care products such as creams and lotions adapted to the patient’s skin type (e.g. water-in-oil products for normal to dry skin; oil-in-water products for oily skin)
Proper diet
Although nutrition cannot prevent pressure ulcers, it can reduce the risk of their occurrence.
Other measures
The following measures also help reduce the risk of pressure ulcers:
- Frequent changes of clothing and bedding for patients who sweat heavily or are incontinent. This helps prevent moisture from softening the skin.
- Use of breathable incontinence underwear
- Placing buttons and seams of night and bed linen in such a way that they do not press on the vulnerable skin areas
- Therapy of underlying and concomitant diseases (diabetes, depression, etc.)
There are special courses on pressure ulcer prophylaxis for family caregivers. In these, you learn how to effectively prevent pressure ulcers. The course content includes information on suitable positioning and repositioning techniques as well as tips on suitable aids and care measures.
What is the course of a pressure ulcer?
An advanced pressure sore heals slowly, even with optimal treatment. Sometimes it takes months for the pressure ulcer to completely disappear. That is why it is so important to pay attention to careful pressure ulcer prophylaxis and to react quickly in an emergency.
However, even after a pressure ulcer has healed, patients have an increased risk of developing a pressure ulcer again at the affected site (recurrence). For this reason, it is highly advisable to keep a particularly close eye on the affected skin area and to carefully protect it from pressure. In this way, it is possible to prevent another pressure sore from forming.
However, the majority of pressure ulcers are superficial and usually heal.
