In 1995, a horse riding accident transformed actor Christopher Reeve from Superman into a quadriplegic. Ten years later, he died as a result of complications from a pressure sore – his tragic death serving to bring attention to one of the most serious problems facing people who are bedridden, immobilized or suffering from a disability.

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pressure ulcers – a clinical insight

While great progress has been made over the past decade in understanding how to best prevent and treat pressure related wounds, the care of pressure ulcers continues to challenge medical staff, nursing staff and other carers alike.

Pressure ulcers are common and costly, posing a serious health concern impacting cost of care, reimbursement and quality of life. In the United States alone, annual estimates show 1.7 million patients develop pressure ulcers with associated health care costs of $8.5 billion – making cost effective pressure care of critical importance, especially in long term and home care environments where pressure ulcer incidence is on the rise.

Our education space is designed to offer an insight into pressure ulcers and pressure care management – what they are, where they occur and the factors that lead to their development. We strongly recommend that you consult your local healthcare professional for further information or clinical advice.

what is a pressure ulcer?

Pressure ulcer n. An area of localized cellular damage to the skin and underlying tissues caused by pressure, shearing and friction or a combination of these forces.

Pressure ulcers (also known as bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue due to unrelieved and prolonged pressure, shear or friction.

why are they significant?

Pressure ulcers are serious problems that can lead to pain, a longer stay in hospital or nursing home, and slower recovery from health problems. They can happen quickly, so it is important to heed warning signs and act swiftly to prevent them occurring or becoming worse.

Pressure ulcers often seem minor, just a redness in the skin to begin with, but they can hide greater damage under the skin's surface. Pressure ulcers can be painful and they can become infected, sometimes causing blood poisoning or bone infections. In severe cases, they can spread deeply under the skin to destroy underlying muscle or bone.

stages of pressure ulcers

Pressure ulcers are grouped into four stages, depending on the depth of the ulcer. An ulcer can range in severity from mild (minor skin reddening) to severe (deep craters down to muscle and bone).

You might hear medical and nursing staff referring to a pressure ulcer as Stage 1, 2, 3 or 4. Stage 1 ulcers are less severe while Stage 4 is more severe.
The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:
Stage I.
Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. For people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away soon after pressure is relieved.
Stage II.
At this point, some skin loss has already occurred – either in the epidermis, the outermost layer of skin; the dermis, the skin's deeper layer; or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, Stage II sores usually heal fairly quickly.
Stage III.
By the time a pressure ulcer reaches this stage, it has extended through all skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.
Stage IV.
In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.

who is at risk?

Every day, without thinking, you make hundreds of subtle postural adjustments that help stave off problems arising from inactivity. But for people immobilized by old age, injury, illness or paralysis – pressure ulcers are a constant threat.

For people unable to move certain parts of their body without help, one or more of these factors may increase the risk of pressure ulcers:
• being confined to bed or chair and unable to move independently, or limited movement only
• a loss of sensation or poor circulation
• skin that is frequently moist due to perspiration or incontinence
• poor nutrition or underweight
• resident of a nursing home or long term care facility
• diminished mental awareness
• suffer from other medical conditions such as diabetes or vascular disease

Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop pressure ulcers.

Age is another critical risk factor. Most pressure ulcers occur in people over 70. Older people tend to be underweight with thinner skin, so making them more susceptible to damage from minor pressure, and prone to the many factors increasing the risk of ulcers.

Other factors, such as friction and shear, also contribute to pressure ulcers. If a person slides down in their bed or chair, blood vessels can stretch or bend and cause pressure ulcers. Even slight rubbing or friction on the skin may cause minor pressure ulcers.

how do pressure ulcers start?

Generally, pressure ulcers occur when a person sits or lies for too long without shifting their weight.

Blood vessels supply oxygen and nutrients to every part of the body, including the skin. Constant pressure in one area means that blood and nutrients are less able to reach the skin in this area.

Imagine the blood vessel is like a garden hose. If you put your foot on the garden hose, the pressure of your foot stops the water from getting through. If the bones inside your body put too much pressure on the blood vessels, then the blood cannot get through, which can cause damage to skin and other tissues.
If the pressure of normal body weight is not relieved in people at risk, it can harm the blood supply to the area, which can lead to skin and tissue damage.

Although unrelieved pressure is the main cause of pressure ulcers, a combination of other factors such as friction (from rubbing, dragging) and shear (sliding down the bed) can also contribute to skin damage leading to a pressure ulcer.

Poor lifting and moving techniques can remove the top layers of skin due to friction with bed or chair surfaces. Repeated friction can increase the risk of pressure ulcers.

Sliding forces ‘shears’ the upper layers of skin away from the deeper layers. This can happen when you slide down, or are dragged up in a bed or chair.

where do they occur?

Pressure ulcers are usually found on bony parts of the body, but can occur almost anywhere that pressure has been applied for a period of time. They are generally found where bones are close to the skin and where the skin presses against a firm surface, such as a chair or mattress.
These diagrams show you where pressure ulcers occur in various positions or postures.

When sitting:
o tail bone (coccyx)
o buttocks (ishium)
o backs of heels
o elbows
o shoulder blades

When lying on your back:
o on the back of your head
o shoulder blades
o elbows
o tail bone (coccyx)
o heels
o toes

When lying on your side:
o ear
o side of your shoulder
o pelvis
o hip
o knee
o ankle bones (malleolus)

how can they be prevented?

Pressure sores can develop quickly, progress rapidly and are often difficult to heal. Yet health experts say many of these wounds don't have to occur. Key preventive measures can maintain the skin's integrity and encourage healing.

Changing position often is the key to pressure care management. But most people at risk are unable to change position on their own, and must rely on a family member or other caregiver to help.

This is why specialized support surfaces are vital – special cushions, pads and mattresses that help protect vulnerable areas or relieve pressure on an existing ulcer. No one support surface is appropriate for all people or all situations. The most effective support depends on many factors, including your level of mobility, your body build and the severity of any existing wounds, and it is important to consult with your physician to find the treatment solution that is right for you.

dynamic support surfaces

Dynamic mattresses offer patients and carers alike one of the most effective and trusted pressure management solutions available. Products are made up of interconnected air cells that cyclically inflate and deflate to periodically apply and remove pressure from the skin's surface.

Unlike static solutions, which can only minimise pressure by maximizing skin contact area, alternating pressure release closely mimics the effect of normal, spontaneous movement – making it one of the safest options for the prevention and treatment of pressure ulcers.

The process involved is called reactive hyperaemia. Hyperaemia is the medical condition in which blood congests in a part of the body. The condition may be subdivided into active hyperaemia, in which blood collects in an organ due to increased blood flow, and passive hyperaemia, in which blood collects in an organ due to an obstruction in the outflowing veins.

Active hyperemia is also used to describe the dilation of arteriolar smooth muscle to increase blood flow in response to an increase in metabolism. Reactive hyperemia is the same but in response to a profound increase in blood flow to an organ after an obstruction. There will be a shortage of oxygen and a build-up of metabolic waste, and reactive hyperaemia (sudden increased blood flow) helps to flush out toxic waster, resupply previously starved tissue and increase oxygenation.

Dynamic pressure relief therefore operates in the same way as the blocked garden hose analogy – pressure is applied to an area of skin for a short period of time, obstructing blood flow to that area, and then rapidly released again to force blood back into the previously deprived area, increasing oxygenation uptake and helping to remove waste build up.