What is a pressure sore?

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1 CHAPTER 5 Skin Care People with spinal cord injuries need to take particular care of their skin as sensation that would normally provide warning of possible skin damage, ie pain, discomfort and extremes in temperature, is often not perceived below the level of the injury. It is essential that a conscious effort is made to look after your skin so that pressure sores do not develop. Pressure sores were known in the past as bed sores, but we now know that there are a variety of causes. Your doctor or the nurses may call them pressure ulcers. What is a pressure sore? Any tissue damage caused by pressure: Pressure closes the blood vessels which supply the skin, causing damage to the tissues. A reddened area develops indicating reduced circulation to that area. If the pressure continues, the skin will continue to be damaged and will die, causing an ulcer or sore to develop. You may be at risk of developing a pressure sore because of: Poor circulation, which means that you have decreased oxygen supply to the skin. Loss of body weight which provides padding over bony prominences. Poor pressure area care. 10 th Edition Dec

2 Preventing skin damage will have several effects: Promote good health. Reduce chance of further hospitalisation. Reduce the time needed to complete rehabilitation. What can you do to prevent a pressure sore developing? Regular pressure relief, including turning in bed, pressure lifts in wheelchair and correct use of pressure relieving devices, such as your wheelchair cushion. Regular checking or having someone check your skin. Relieving pressure from areas of the body which are marked (see blanching of skin ). Constantly being aware of causes of skin damage (see below). Maintaining clear, dry skin. Remember: Most pressure sores are preventable. Areas of the body which are prone to pressure sores All bony areas around the buttocks and sacral areas and the ischial tuberosities (the bony prominences which take your weight when you sit). See figure 4-1. The cleft at the top of the buttock crease. This is called the natal cleft. Hips Ankles Shoulder blades Knees Toes Elbows 10 th Edition Dec

3 Figure 4.1: Bony Prominences Causes of skin sores Pressure. Shearing: Force applied to the internal structures, mainly when sitting up in bed or with poor posture in the wheelchair. Like a hand in a glove, the ischial tuberosities (or other bony structures) are forced away from their natural position, shearing the tissues and, more importantly, the blood vessels. Moisture: If you are unable to dry yourself, ensure that you direct someone to do it properly. If you have a bowel or bladder accident, ensure that you wash properly or this can also cause burning of the skin. Tight clothing: In particular the seams from jeans or tight shoes can mark the skin. 10 th Edition Dec

4 Burns: It is important to check water temperature in the shower on an area of your skin where you have sensation. Be sun smart, do not sun bathe and be wary of hot footpaths on your wheelchair in summer. Friction: Can be caused by dragging yourself along the bed sheets causing friction, inadequate clearance while transferring over the wheel of the wheelchair or by spasm (it is important to take care to maintain medication). Splints: Must be watched carefully for pressure marks, particularly when first worn. Diet: Poor diet can lead to skin deterioration and affect tissue healing. Catheter tubing or straps: If tubing is sat on inadvertently or the strap is applied too tightly. Other Seats: Hot car seats, unseen foreign objects on lounge/outdoor chairs. Blanching of skin If you, or someone else, discovers a red mark on your body, gently press the area. If the mark whitens easily ( blanches ), the blood supply to the skin is healthy and the tissue should soon heal. If the mark stays red however, the blood supply is impaired, the tissue is damaged and the area will take longer to heal. If your skin does not blanch, you must make the effort to prevent further damage, eg not sitting if you have a mark on your buttock. If the mark does not resolve or a pressure sore develops, notify your doctor/nurse immediately. 10 th Edition Dec

5 The four stages of pressure sores and how to identify and manage them The following information is a guide to help you identify and manage your skin at home. It gives you the basic information you will need. Other specific information will be given to you during your rehabilitation. 1. A Stage One Pressure Sore Description: The skin appears red or discoloured, not broken, but may or may not blanch (see blanching for description). It does not fade or change colour after being free of pressure for 30 minutes. Management: Remove the item causing pressure, eg shoes, belt, tight clothing. Keep the area free of pressure. If you must sit on the area, do extra pressure lifts and only sit for very short periods, eg maximum one hour. Avoid pressure on the area when in bed and regularly turn yourself to avoid making other areas red. Check a reddened or discoloured area regularly to see if it is improving or deteriorating. If it improves it should fade in a few days but can take up to a few weeks if you do not stay off it. If it deteriorates then you need to have it checked by your local GP or by a doctor in the SIU Outpatient Department. 10 th Edition Dec

6 2. A Stage Two Pressure Sore Description: The top two layers of skin are broken, creating a shallow open sore (it can be a blister). Some clear fluid may be present. If there is infection then the surrounding skin will be red and hot. A greenish discharge and odour may be present. Management: Keep the area totally free of pressure at all times. Initially cover it with a dry sterile dressing pad. Have the area checked by your local GP or by a doctor in the SIU Outpatient Department as soon as possible, as this type of pressure sore will require regular dressings until healed. Check the area when dressings are changed to see if it is improving or not. Regular reassessment by your treating GP or doctor in the SIU Outpatient Department is likely to be required in conjunction with Royal District Nursing Service (RDNS) who are available by negotiation to manage the dressings. 10 th Edition Dec

7 3. A Stage Three Pressure Sore Description: The break in the skin extends deeper into the tissue layers and will include the subcutaneous fat tissue. The sore will be much deeper than a Stage 2 sore and will take longer to heal. Management: As for a Stage 2 pressure sore, but it is likely that you will need to be admitted to hospital for treatment. This type of sore can take many weeks or months to heal. Once healed you will have to complete a sitting program before you can return home. 4. A Stage Four Pressure Sore Description: The skin breakdown is very deep, it will involve the muscle tissue and possibly the bone as well. There will be a large amount of dead tissue and discharge present. 10 th Edition Dec

8 Management: This type of sore means that you will be admitted to hospital and surgical repair is the main course of treatment (even amputation may be necessary). This will mean months in hospital as once surgery is completed you cannot put pressure on the area for six weeks. You will then need to complete a sitting program before you can return home. It is very important to prevent pressure sores. If you have one you must treat it immediately. To heal it you must keep all pressure off the area. This means staying in bed, which means time off work, loss of wages and loss of activities. If you are in bed for long periods then you become more susceptible to chest and urinary infections. So remember to always check or have your skin checked twice a day, this will help you to identify any problems, eg tight clothing, and deal with them before you get a pressure sore. Remember: All pressure sores, no matter how minor they appear, are a major problem and must be treated as such. 10 th Edition Dec

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