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Prevention and Rehabilitation of Pressure Ulcers

Michael Kosiak , MD

MAY,1991. Decubitus. VOL. NO.2

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Every care provider is well aware of the complications manifested by the occurrence of ulceration in the chair- or bed-ridden patient.

The healthcare professional is being required, with increasing frequency to maintain and rehabilitate the elderly and severely disabled.

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DEFINITION

Pressure ulcers are localized areas of cellular necrosis which usually occur over bony prominences which are subjected for prolonged periods of time to pressures in excess of capillary pressure.

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INCIDENCE

The incidence of ulcerations is considerably greater in the spinal cord-injured hospital population and many deaths in this group of patients can be attributed to complications arising from the presence of pressure ulcers.

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DISTRIBUTION

While pressure ulcers can develop over any area of the body subjected to supra-capillary pressure for a sufficient period of time.

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PRIMARY FACTORS Pressure Working with normal and paraplegic rats, we repo

rted that microscopic examination of rat muscle 24 hours after being subjected to pressure of 70 mm Hg for two hours showed a decrease or loss of cross-striations and myofibrils, hyalinization of fibers and neutrophilic infiltrations.

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PRIMARY FACTORS Pressure When complete relief of pressure was

provided at regular five-minute intervals, as with an alternating pressure support system, the tissue showed consistently less change or no change at all when compared with tissues subjected to an equivalent amount of constant pressure.

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PRIMARY FACTORS Pressure This was true even at pressures as high as 240 mm

Hg for three hours (Kosiak, 1959).

Pressure as high as 190 mm Hg when applied either constantly or intermittently for up to one hour showed no microscopic changes.

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PRIMARY FACTORS Friction and Shearing Dmsdale (1973), working with swine, demonstrate

d significant skin breakdown when the tissue was subjected to both pressure and friction, at a pressure significantly less than that when necrosis was caused by pressure alone (45 mm Hg versus 290 mm Hg).

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PRIMARY FACTORS Temperature Raising tissue temperature increases cellular

metabolism and, therefore, increases the risk of ischemic necrosis.

Aging After the third decade, a progressive decrease in skin

pliability and elasticity has been reported .

whereas after the fifth decade, a rapid decrease in blood flow through the skin occurs.

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CONTRIBUTING FACTORS Nutrition Increased emphasis has recently been placed

on the role of nutrition during the acute and convalescent phases of illness, especially on the negative nitrogen and calcium balances that inevitably appear after an acute insult.

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CONTRIBUTING FACTORS Nutrition Protein insufficiency inhibits or prevents the

healing of ulcers.

For a good metabolic response, the patient with a pressure ulcer should be eating 80-100 gm of protein each day.

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CONTRIBUTING FACTORS

Edema

Anemia Endocrine Disorders Diabetes mellitus is the most frequent

hormonal problem.

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PREVENTION

Pressure ulcers are entirely preventable.

They need not and should not occur.

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GENERAL PREVENTIVE MEASURES Education Identification of the high-risk patient Those persons with impaired mobility, especially in

combination with decreased sensation or alteration in the level of mental awareness, are obvious candidates for skin breakdown if they are neglected.

A single episode of neglect of a comatose or anesthetized patient for even an hour may result in pressure necrosis.

Special consideration must be given to patients who require sedation or mood-altering drugs.

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GENERAL PREVENTIVE MEASURES Recognition of Impending Skin

Breakdown

Specific Preventive Measures for Elimination or Reduction of Pressure

Position changes must be made around the clock but not less frequently than every two hours.

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MANAGEMENT General Measures maintenance of the patient in a good

state of nutrition and hygiene should be of high priority both to sustain healing and to avoid infection.

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SPECIFIC MEASURES Pressure Relief The ulcerated area should never be subjected to

any pressure unless absolutely necessary for resting support.

Elimination of Shearing or Friction.

Reduction of Heat and Moisture Build-up.

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SPECIFIC MEASURES Debridement Mechanical Debridement

Chemical Debridement

Control of Infections If infection is prevented or controlled, heal

ing begins to occur promptly and rapidly.

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SUMMARY

The importance of providing pressure relief to the areas supporting the weight of the body must continue to be stressed and materials and methods must never be substituted for sound nursing care.