Pressure Ulcers (pressure sores)

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Last Medical Review: March 26, 2020
Medically Reviewed by Dr. David Costa Navarro
Pressure ulcers (pressure sores) (March 26, 2020)


The first preventive intervention consists in identifying the conditions that can favor the development of pressure ulcers and patients at risk. The elderly represent the population at higher risk of ulcers due to the frequent concomitance of factors such as incontinence, debilitation, malnutrition and some diseases that facilitate their formation in various ways (diabetes, circulatory disorders, cerebrovascular diseases).   In the prevention of pressure sores, assistance must be aimed at eliminating or reducing the main risk factors, the first of which is immobility.The first and most important measure is in fact to implement a frequent and regular change of position of the sick (at least every two hours) both day and night: if no action is taken in this regard, any other treatment is bound to prove ineffective. The position on both sides will alternate with the supine one and for short periods the prone one (belly down) will be used, if it is tolerated. If you use the semi-sitting position (for no more than two hours), the tendency of the body to slide forward with the use of suitable supports or cushions will be countered to avoid the risk of injury from rubbing the skin against the sheets or the work surface. support. The change of position must be performed by lifting or rotating the patient gently and not crawling his body on the bed. The maneuver requires the simultaneous presence of two people. These people must not have long nails, prominent rings, or a watch on their wrist, in order to avoid causing small lesions destined to turn into real ulcers.   Often organizational problems and a shortage of care staff do not allow these intervals to be respected in patient mobilization. To extend the time between one rotation and the other, some devices can be used that allow you to relieve the pressure on the areas of support of the body, knowing however that some are effective others less.

  • Particular foam mattresses with silicone pads to be inserted at the level of the sacrum, neck and heels are able to prevent ulcers and improve the “comfort” of the patient. The silicone distributes the pressure over a larger surface, also acting as a protective pad. Advantageous, if used correctly, there are also special air mattresses connected to an electric pump which alternately inflates and deflates the sections (horizontal or vertical) of which they are composed. The patient remains alternately resting now on one hour on the other, thus varying the compression areas. However, these are noisy devices that cannot be used in obese patients: the opportunity for their use must be assessed on the basis of the seriousness of the risk.
  • Normal pillows are ineffective for relieving pressure, while feather pillows have great insulating properties and are much more useful. However, they should be frequently squeezed (every 4 hours) to redistribute their contents and keep them soft.
  • Lambskin (fleece) can reduce the incidence of superficial friction injuries. They must be washed frequently and replaced when they lose softness. Although natural fleece is less resistant to frequent washing than synthetic, it offers superior performance.
  • To protect the heel area from the weight of the blankets, there are special blanket arches.
  • Instead, avoid the use of foam or inflatable donuts: they move easily with movements and can cause compression and friction damage.

The sheets must be soft, well stretched and without mending or coarse seams and when they are wet they must be replaced immediately. Absolutely to avoid the direct contact of the skin with waterproof material (tarpaulins or rubber). When these devices become necessary, they must be placed under a crossbar of soft and absorbent fabric. There are comfortable ” disposable ” sleepers on the market. Any foreign bodies must be scrupulously removed from the bed surface. Even if of modest volume or apparently banal (e.g. bread crumbs) they could equally be the cause of grazes. The pan should be positioned with the utmost caution. To prevent the skin, perhaps sweaty, from rubbing against the pan surface, it can be covered with a sheet. In risk cases it should be replaced with special disposable crosspieces or diapers.   Hygiene of the person Careful hygiene of the most vulnerable regions, especially in the case of incontinence, represents another essential condition for the prevention of ulcers. It is best to carry it out with water and acidic detergents, better if liquid (eg Saugella, Lactacyd, etc.), drying the parts well with light buffering. In the event of frequent washing, the use of small quantities of oil or protective creams, such as those indicated for infants (base cream), can help keep the skin elastic and prevent maceration in cases of incontinence. Avoid using talcum powder and denatured alcohol, products containing alcohol and energetic cleansers that dehydrate the skin making it more easily prone to injury. Massages or frictions with soapy or camphorated alcohol not only do not prevent pressure ulcers (they risk being injurious), but they must not even be performed in the areas around the lesion.

The treatment

When the preventive measures prove insufficient, the skin becomes red and shiny, the first small lesions appear, it is necessary to consult the doctor or home nurse. In any case, the wound must not be subjected to pressure; the mobilization of the infirm must therefore continue with even greater attention. To avoid the risk of infections, the lesion must be kept constantly clean; for this purpose, washing with physiological solution or lukewarm Ringer is useful (the cold in fact delays healing). Washing should be done by low pressure or drop irrigation: a jet sprayed with a syringe can cause trauma and increase the susceptibility of the lesion to infections. Cleansing with disinfectants should be limited to infected or contaminated lesions (e.g. in areas in contact with urine or feces). It is preferable to use non-irritating chlorhexidine-based products contained in convenient sterile packs ready for use (e.g. Neoxinal). In most cases it is not necessary to use creams, ointments or antibiotic-based solutions.

  • The superficial lesions can be protected from external bacterial contamination, especially in case of incontinence, with special semi-permeable adhesive films of transparent synthetic material (eg Opsite, Tegaderm) that allow the fabrics to breathe, maintaining an optimal temperature and a humid environment that favors the healing. These dressings should not be applied to infected or deep lesions.
  • Hydrocolloid dressings (eg Duoderm, Intrasite) are usefully used on ulcers with medium-abundant exudate, which have an impermeable external layer and an internal layer that absorbs the exudate forming a soft gel that expands to occupy the inside of the sore, maintaining the right degree of humidity which accelerates healing. They are removed without trauma to the wound and the gel is removed with physiological solution.
  • In the case of deep non-suppurating wounds, hydrocolloid pastes (eg Duoderm pasta) are used instead.
  • Traditional dressings, such as cotton and gauze, should not be used directly on the ulcer because they absorb exudates, attach themselves to the wound, dehydrating it and therefore hindering its healing, and cause damage upon removal.

Powder products should not be applied to the lesion due to the tendency to form crusts. If prescribed, the ointments should be applied in a thin layer, removing the residues of the previous application with lukewarm physiological solution. Very often, a thick, blackish crust forms on the ulcer, which must be surgically removed by the doctor. The scabs in fact delay the wound healing and can favor the onset of infections. When ulcers are extended and lose fluids, they cause a high loss of proteins, increasing the protein and caloric needs which are already high due to the possible presence of fever, infections and malnutrition. In many cases it is therefore essential to supplement the diet with dietetic products (e.g. Ensure, Fresubin, Nutrodrip).

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