Pressure ulcers or sores are wounds that develop on the skin and in underlying tissue. Education for the patient, caregivers, and the team of clinicians is the best method of prevention. When they occur, they are often found over areas where bony prominences exist. They are caused by a combination of ongoing pressure to the area, friction, and moisture. As pressure squeezes tiny blood vessels that provide the skin with oxygen and nutrients, tissue damage from cell death results and a pressure sore may form. Untreated, it may break open and become infected.

Individuals most at risk for pressure sores are those who are unable to change positions independently while in a bed or in a chair; those who are incontinent due to poor bladder or bowel control; those with poor nutrition and hydration factors; those with decreased mental awareness and sensory perception; or those who are in bed with the head raised in more than a 30º angle.

One of the most effective methods of preventing pressure sores in patients is by utilizing an assessment tool such as the Braden Scale. The scale ranks from one to four a patient’s sensory perception, mobility, moisture, or degree to which the skin is exposed to moisture, activity, mobility, and friction of outside material against the skin. The lower the score on the Braden Scale, the more likely it is that the patient will develop pressure sores. Knowing the risk level enables greater vigilance by the clinical staff to implement care that will prevent sores from developing, prevent them from worsening, or more effectively manage existing sores.

There are various interventions that can be employed in pressure sore prevention. For patients in a bed, they should be turned every 2 hours. For those in a chair, they should be repositioned every hour. Controlling incontinence and reducing moisture exposure to skin can be achieved by using skin cleansers and ointments that provide a barrier to the skin, and by using pads that draw or wick moisture away from the skin.

The author tends to a patient’s pressure ulcer.

Patients in a bed should not have their heads elevated at a greater than 30º angle. A greater angle redistributes weight across various pressure points rather than concentrating on one central area. In addition, when moving patients in a bed, clinicians should use a draw sheet to lift and move the patient rather than pulling the patient up in the bed. This reduces friction and shear to the patient. For patients who spend much of their time there, the bed should have a pressure redistribution surface so that pressure points can be varied. In addition, pressure redistribution cushions should be utilized for the chairbound patient.

Wound care clinicians should work closely with rehabilitation therapists to determine the best surfaces for the patients’ beds and chairs. This can prevent pressure sores while still enabling easy mobilization of the patient. Sitting protocols must also be coordinated between the rehabilitation therapist and the wound care clinician. This will enable a patient to be out of bed for the maximum amount of time on proper pressure redistribution cushions and prevent pressure sores from developing.

A multidisciplinary approach to care extends beyond the therapist and wound care clinician. Consultations with nutritionists can improve the overall nutritional and hydration needs of the patient. Coordination with occupational and physical therapists to maximize mobility will improve the overall condition of the patient. Including the primary care physician, primary nurses, case manager, and respiratory therapist further assures a comprehensive team management approach to patient care.

Education on early identification and prevention of pressure sores with the patient and caregivers can prevent pressure sores from forming. Regular weekly meetings with the patients and their caregivers ensure appropriate attention to this area of care and consistency in care measures for the patient.

Despite all preventive measures, pressure sores may form, particularly in those with advanced age, low blood pressure, or poor nutrition, or with other factors such as diabetes, anemia, obesity, smoking, and other conditions that decrease the ability of the body to get oxygen to the tissue. While pressure sores are not an independent predictor of mortality, they can be a marker for other diseases and comorbidities. Pressure sores can add to a patient’s length of hospital stay, increase the risk of complications, and delay overall recuperation. In addition, if untreated, they can become infected and result in sepsis and renal failure, and on their own can be life-threatening to a patient.

Treating pressure sores begins with controlling or eliminating the causative factors of the sore, and preventing infection. The wound should be cleaned with nonviable tissue removed. Pressure should be redistributed away from the pressure points. An increase in oxygen flow to the wound from internal and external sources is key to treatment. An increase of nutritional and fluid status via proper circulation supplemented by oxygen from external ventilation sources will help, particularly when combined with a reduction of moisture to the area.

Maintaining a normal body temperature, bacterial balance, pH levels that are neutral to mildly acetic, and adequate moisture levels at the site of the wound will contribute to healing. During the treatment and healing process, the wound and surrounding tissue should be protected and the patient should be provided with medication for the reduction or elimination of pain.

Even with treatment, pressure sores can recur, particularly in patients who are paralyzed. As the wounds heal, the new skin that forms is less strong than that which existed before. Treatment for recurring pressure wounds remains the same, with efforts toward prevention essential.

In summary, education about pressure sores for the patient, the caregivers, and the team of clinicians is the best weapon in preventing the formation of pressure sores. This includes using risk assessment tools for each patient and performing systematic skin assessments where pressure wounds may be likely to form, and then reducing the risk factors. In the event that pressure sores form, immediate and regular treatment in the care of the wound can greatly reduce the healing time.

Cynthia Lange-Koschitz, RN, BSN, is a certified wound ostomy continence nurse at Good Shepherd Rehabilitation Network Specialty Hospital, Bethlehem, Pa. For information, contact .