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Pressure Ulcers

View profile for Kimmo Boote
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Pressure Ulcers – what they are, who is at risk, prevention & treatment.

This is a Photo of Maggot Therapy – which is occasionally used to treat serious Pressure Ulcers.

Pressure ulcers are an injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are sometimes known as "bedsores" or "pressure sores".  Pressure ulcers can range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle.

They can occur in any patient and at any age. This article will focus on adult patients, and in particular, those more prone to suffering from them.

Severity Grading for Pressure Ulcers 

Grade one

A grade one pressure ulcer is the most superficial type of ulcer. The affected area of skin appears discoloured – it is red in white people, and purple or blue in people with darker-coloured skin. Grade one pressure ulcers do not turn white when pressure is placed on them. The skin remains intact, but it may hurt or itch. It may also feel either warm and spongy, or hard.

Grade two

In grade two pressure ulcers, some of the outer surface of the skin (the epidermis) or the deeper layer of skin (the dermis) is damaged, leading to skin loss. The ulcer looks like an open wound or a blister.

Grade three

In grade three pressure ulcers, skin loss occurs throughout the entire thickness of the skin. The underlying tissue is also damaged, although the underlying muscle and bone are not. The ulcer appears as a deep, cavity-like wound.

Grade four

A grade four pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles or bone may also be damaged.

People with grade four pressure ulcers have a high risk of developing a life-threatening infection. 

The Problem

Whilst the scale of the problem is enormous, it is not widely understood to be such a big problem !

Over 15 years ago, the Royal College of Nursing released a report, in which it stated :

Pressure ulcers represent a major burden of sickness and reduced quality of life for patients and their carers. The financial costs to the NHS are substantial. It has been estimated that preventing and treating pressure ulcers in a 600-bed general hospital costs between £600,000 and £3 million a year.’

It was estimated that the cost of treating a patient with a Grade 4 pressure ulcer was £40,000 (Grade 4 being the most serious type of pressure ulcer).

The NICE guideline was written to provide guidance on the prevention and treatment of pressure ulcers in primary and secondary care settings. The recommendations of the NICE guidance represent the fundamentals of care that should be provided to patients in the NHS or in settings where the NHS helps with medical care.

Risk Factors

The people at higher risk of developing pressure sores include those:

  • Seriously unwell
  • With poor nutritional status
  • Who have deformities from muscular/bony disorders, limited mobility or who cannot reposition themselves
  • Who have had previous pressure ulcers
  • Who have impaired tissue perfusion, such as a peripheral vascular disease
  • The more factors that are present, the greater the risk of pressure sores developing
  • External contributing factors include poorly made/designed furniture in which the people spend prolonged periods of time and lack of organizational structure to ensure avoidance of the development of pressure sores.

Risk Assessments

Any patient coming into care with the NHS should be risk assessed for the possible development of pressure sores.

Patients who are at higher risk than normal of developing pressure ulcers should:

  • Have areas of their skin at risk be checked to ensure skin integrity,
  • Record any colour changes to the skin along with differences in heat, firmness, and moisture.

All patients should have a risk assessment in their care, and have individualized plans to ensure that pressure ulcers do not develop, or if present, then there must be a clearly documented treatment regime to follow. Any changes in the patient’s condition meaning that they might be more likely to be a risk must be noted and acted upon in terms of their care.

Prevention

Palpation of any reddened areas will help to determine if the skin blanches, i.e. returns to its normal colour. If not, then this area is at risk of breaking down, and the following steps are recommended with up to 2 hourly skin assessments until the skin begins to blanch after pressure.

Actions

Reposition the patient at least every 6 hours, and for those at high risk, at least every 4 hours. Assistance to move the patient may be required to ensure that these regimes are followed.

High risk patients may need high-spec. foam mattresses, as well as for patients who will undergo surgery in the theatre room.

Seating arrangements with appropriate materials as cushions should be made, particularly for high risk patients who sit for long periods of time, the same recommendations being made for wheelchair users.

Barrier creams should be considered to prevent damage to the skin in adults with risk of developing skin breakdown due to moisture, e.g. patients with incontinence-associated dermatitis, inflamed skin or oedema.

There are certain actions which should NOT be undertaken.

  • Do not massage the skin
  • Ensure that the patient’s nutritional intake is adequate but do not offer additional nutritional supplements in the hope of avoiding pressure ulcers
  • Similarly, do not give intravenous or subcutaneous fluids in patients who are adequately hydrated.

If you want further information about this particular topic, or wish to discuss the possibility of bringing a claim for Clinical Negligence - or indeed any other type of injury, please contact the Dutton Gregory Clinical Negligence Team on (01202) 315005, or email c.hayter@duttongregory.co.uk    

NB This article does not constitute legal advice and should not be relied on as such. No responsibility for the accuracy and/or correctness of the information and commentary set out in the article, or for any consequences of relying on it, is assumed or accepted by any member of Dutton Gregory LLP.