As with everything I write, I take inspiration from areas of care that I deal with regularly. I want to give you the information that is floating around in my head in the most comprehensive way possible. Pressure sores and everything you need to know about them may go into more detail than you need (I am specifically talking about the stages of a wound) but I regularly come up against people not truly understanding why I am so diligent about wound care and why it is so important. I feel if you understand why a wound is so deep you will understand why I am promoting good nutrition and regular movement so much.
What is a pressure sore?
A pressure sore (also known as a bed sore, pressure ulcer or decubitus ulcer) is an injury to the skin and underlying tissue. They generally develop in boney areas with little fat or padding to protect the skin. Common places for pressure sores to develop are the heel, sacrum (tailbone), the spine and the hips. However, an area that spends prolonged periods of time in contact with a bed or chair has the potential to develop a sore. Depending on the past medical history, the reason the ulcer developed and what the current physical situation is like, pressure sores can heal quickly, may need extensive treatment or may never heal.
When we begin to care for someone, it is important that we have a full understanding of their medical history. Whether it is your mum, a family member or you have been hired to provide care, in my opinion, the single most important piece of information you must know (and fully understand) is a full medical history. Having a comprehensive medical history (and be aware that this must include everything unrelated to the current complaint i.e. dementia, stroke, cancer) sets the foundation for everything that is to come. Some parts of the medical history immediately make you aware of the risk of pressure sores, but other illnesses (such as peripheral neuropathy) may not be visible and therefore, won’t make you aware of the risk unless you have a complete history.
Whilst anyone can get a pressure sore, the following factors put you at a much higher risk:
- immobility due to paralysis
- being confined to bed due to illness, old age or surgery
- urinary and bowel incontinence
- Age – being 70 or over increases your risk due to the presence of illness and the deterioration of the condition of the skin
- Skin condition being poor due to illness, circulation, medications and thinning of the skin as we age
- Poor nutrition can lead to poor skin and muscle condition and tone
- Medical conditions which affect blood supply such as diabetes, kidney failure, heart failure, Multiple Sclerosis and peripheral arterial disease
Signs and Symptoms of Pressure Sores
The chances of you caring for a pressure sore are pretty slim (unless of course, you are a nurse!) and a lot of what is described below may go over your head, however, it is important to understand how each stage of the wound is affecting the skin. This knowledge will, in turn, assist you when you are trying to prevent a pressure sore occurring or heal one that has just begun to form.
According to the NHS, pressure sores have 4 stages.
You may notice that the skin has discoloured. It may be red or even have a purple or blue hue to it. The skin may feel different to other areas of the body it may be hot or cold, may feel hard, soft or spongy to the touch. Generally, the area will be painful to touch or when putting pressure on it. Due to poor circulation in the area, when you touch it, it may turn white and take some time to return to the normal colour of the area. These are all early signs that a pressure sore may develop. There is a possibility of preventing a breakdown of the skin at this stage – more on how to do this, below.
The top layers of skin are affected and there is some skin loss of the epidermis, dermis or both. The wound will look like a skin abrasion or a clear blister. There should be no bruising evident.
If there is a blood blister or bruising evident (and no broken skin), this indicates that there could be a deep tissue injury. A deep tissue injury is defined as “a pressure-related injury to the subcutaneous tissues with the skin intact”. Deep Tissue Injuries need immediate treatment from a qualified specialist, such as a wound care nurse.
A stage three pressure sore will have full thickness skin loss. This means that the wound will be deep, however, you will not be able to see (or feel) bone or tendon. There may be slough in the wound. Slough is ulcerated skin that is coming away from the wound and can vary in colour from yellow or green to tan or brown. Sometimes you cannot assess the depth of a wound until the slough has been removed, however, it is only present in stage three or four ulcers.
Pressure sores on the heel can sometimes present with a hard, black scab on top. This is what is known as eschar and it is the body’s way of protecting the area. This must not be removed.
In stage four, the pressure sore may extend to the muscle, tendons or the supporting structure of the area. Bone will either be visible or palpable. The depth of the wound will vary depending on how much adipose tissue (fat) is in the area. For example, the ear can have a stage four wound, even though there is little to no fat and a stage four wound on the buttock can be very deep.
What to do Next
If you suspect that the person you are caring for may have a pressure sore, the first thing I suggest is to take a picture. There are several reasons for taking a picture. The first being that you now have a baseline for what the wound looked like when it was originally noticed. Secondly, the person you are caring for may not be able to get out of bed and therefore it can be difficult to get them to a doctor to begin the process of treatment and finally, the wound care specialist will use it to enter into the care plan and documentation of the wound.
Depending on who you liaise with regarding care of your loved one, they are your first port of call. Some people have a community or public health nurse that calls in and checks on them and some people only have their primary care physician or GP to go to with queries. Whoever it may be that you liaise with, you need to contact them immediately and discuss your concerns regarding pressure sores. Generally, a wound care specialist will then be contacted to visit and carry out an assessment and begin the care and treatment of the wound.
* Please note if the person you are caring for is a client, you need to ask their permission before taking a photograph.
Treatment varies from wound to wound and person to person, so I am not going to talk about the specifics of dressing a wound as it would be impossible to even begin to cover what goes into treating a wound. It may be dressing or a vacuum, the wound may need to be seen by a surgeon and in some extreme cases amputation of toes or parts of limbs may be best to stop the wound and infection spreading.
Here are some tips that will aid the treatment being completed by the wound care specialist
- Gel Cushions – a gel cushion under the bottom when sitting can help reduce the pressure put on bony areas.
- Air Mattress – For those that are confined to a bed, an air mattress is an invaluable piece of equipment. The design helps alleviate the pressure and can be a great tool in reducing and treating the occurrence of pressure sores.
- Side to side positioning – for treatment of a wound to be effective, pressure must be relieved from the area in question. Side to side positioning is one of the most basic ways of doing this. It is important to do this on a regular basis (2-4 hourly, depending on the wound, skin condition and the recommendations of the wound care specialist).
- Keeping the skin dry – removing moisture (such as sweat) and ensuring that the area is dried thoroughly when washed.
For more information on how to prevent pressure sores, I have written this post. Just click the picture below and it will take you straight there.