Podcast Episode 29: Pressure Ulcers - Part 1

Hello, my name is Sylvie Hampton and I'm an independent tissue viability nurse consultant working throughout the UK. I have nearly 30 years experience in wound care and pressure ulcers and in this particular podcast, part one, I'm going to explain pressure ulcer development and assessment in the paler and the darker skin. It's important to understand why pressure ulcers occur and how to assess and how to prevent. There is absolutely no difference between the terms decubitus ulcer, pressure ulcer or pressure sore. All of these are used interchangeably, although personally I prefer pressure ulcer or pressure injury. The term we should never ever use is bed sore. This is a misnomer as pressure injuries are more likely to occur in a chair than in a bed, I was actually informed that it could be as high as 80% of pressure ulcers occur when somebody is sitting in a chair. Therefore the term bedsore gives the wrong impression and means that someone may be sat out of bed for longer thinking that the injury will not occur in the chair and that they are safe when they are not. Immobility is the cause of pressure ulcers and so it is that immobility that needs to be addressed. Recognising a developing pressure ulcer is so very important but this recognition is different when you're looking at pale or darker skin and we need to adapt the assessments to ensure the patient's safety. If I were to place someone with pale skin on a sheet of glass and go under the glass where the bony prominence connects with that glass, area will turn white. This is because the pressure ulcer pushes the blood out of that area. Depending on the condition of the person, if I leave them there for a while, could be as long as two hours, the area will be white. But when I turn them over, by the time that area is facing me, it will be bright red. That's where the body thinks, oh goodness, there's been a shortage of blood here, I must react really fast to restore the blood supply. And this is called reactive hyperemia or blanching redness. If I press my finger in the centre of this it will turn white that's when I push the blood out again so you've now got a white area where my finger was. If I release the finger the reactive hyperemia will occur again and that area will turn red. This tells me there's no pressure injury however if that redness lasts longer than 20 minutes then I must take it as a warning that an injury could be occurring and that it's urgent to ensure they are repositioned regularly. How often they're repositioned is dependent on that redness. If the redness stays for 20 minutes after two hours then two hours is far too long, needs to be reduced to one and a half hours and if there's redness then then you need to reduce the time further. However if after two hours there's no redness at all then you could extend that period of time between turning. Also this will be dependent on whether the mattress and or the chair cushion is upgraded. If I leave someone for two hours who's got low blood pressure or is ill or murribund then it's possible they will develop a pressure injury within that two hours. I may be able to leave a fit person healthy person even up to four to six hours if they have a good blood supply. Once the blood has been excluded small clots of blood form in the little tiny weenie micro vessels at the edges of that white area and when the pressure is relieved instead of re-flooding the area the blood is prevented from entering that area by those little blood clots. This will now look bright red and inflamed it's actually inflammation and not blood that redness and that's known as a grade or a stage or a classification one. That's a pressure injury that's occurring and it could be too late to save the tissue. Nevertheless we should act urgently with extra repositioning and better equipment. The darker skin however is much harder to assess as the white area is not seen and when When the person's moved, the area will darken. If it remains darker for 20 minutes then it's the same as above, you must do something about it. More frequent repositioning and better equipment. A normal healthy person moves around quite a lot, even in sleep, we roll over, we toss, we turn. And we might get up to go to the bathroom, and all of this provides relief for the bony prominences that have been bearing pressure while we're in bed. When we sit in a chair we constantly cross our legs, lean forward, slide down in the chair onto our sacrum to relieve pressure and we do this unconsciously as the pressure begins to develop and we start to feel uncomfortable. Our problem is that some people are unable to relieve that pressure and there are those who do not feel the discomfort and the pressure and we need to be fully aware of this and assess how often they need to be repositioned when in bed or in a chair. People who are particularly at risk are quadriplegic patients, anyone who's unconscious, anyone with weakness from disease or illness or even someone who is very depressed may well develop a pressure injury. Pressure ulcers develop anywhere on the body but it's particularly over bony prominences such as the sacrum or heels or hips etc. Any area that has a bone pressed against a firm surface pinching the tissues between those two surfaces. If we sit in a chair 75% of our body weight goes down on two very small bones under the buttocks. They're pointed and they become uncomfortable very quickly. Anyone who sat in a cinema for two hours will be very friendly with these two little bones and the sacral area as it becomes more and more uncomfortable and numb. If we lay on a soft bed then the body weight above the bony prominence is far less than if sitting in a chair and the softness of the mattress would redistribute the pressure. To explain this, if we were to go deep sea diving, even though the pressure from the water is far, far higher than the pressures we experience when sitting in a chair, we would never develop a pressure ulcer, and that's because the water provides absolutely equal pressure right across the body. The soft mattress or soft cushion that we use in a chair is behaving a little like the deep water and is flowing around the bony prominence. And although it doesn't give us 100% good pressure relief, it does give us better pressure relief if it flows around that bony prominence. It sort of spreads the load. Ankles and heels have very little fat on them and very little blood supply. Therefore even on a soft mattress or on an air mattress those areas are in danger if someone is not frequently moving. This risk is much much higher if the person has arterial disease in the lower limb. Podcast part two of this particular session will explain how to identify this arterial disease and what to do to prevent any injury to the heel and the ankle and podcast three will explain how to tell the difference between a pressure ulcer and a moisture lesion and will simplify grading or staging or classification of pressure ulcers. Those are all used interchangeably, grading, staging and classification. Some people still use grade 1, grade 2 but some like the USA tend to use stage so stage 1, stage 2 and classification is quite a common term used across Europe which would be classification 1 or 2 and so on. So prevention of pressure ulcers relies very much on assessment and it's really important to get that assessment right. When we have that assessment and we've done that assessment and we're worried that we are going to develop a pressure ulcer then we need to look at how we prevent that and that will be a further podcast. Thank you very much for listening. I hope it's helped a little a bit.