Detailed explanation of pressure sores and nursing guidelines

| What are pressure sores?

Pressure sores, also known as bedsores, are caused by long-term pressure on a part of the body, which affects blood circulation and leads to tissue necrosis caused by lack of nutrition in the skin and subcutaneous tissue. They often occur in comatose and paralyzed patients who have been bedridden for a long time and in a fixed position. The skin appears pale, grayish white or bluish-red, with mild edema, clear boundaries, and numbness or tenderness. As the disease progresses, the skin turns black and purple, and blisters and ulcers appear, even deep into the subcutaneous tissue, muscles, and bones.

Pressure sores are not primary diseases, but are mostly caused by bedridden patients who do not receive adequate care. Pressure sores can cause a series of harms, increase the patient's pain, aggravate the underlying condition, prolong the course of the disease, and even cause sepsis and endanger life.

Areas prone to pressure sores

1. Supine position: For patients who are bedridden for a long time, lying in the supine position for a long time, pressure sores are prone to occur in the occipital process, scapula, sacrum, ischial tuberosity and other parts. The most common parts are the sacrum and ischial tuberosity.

2. Side-lying position: For patients who have been bedridden for a long time and lie on their side for a long time, pressure sores are likely to occur on the greater trochanter of the femur and the lateral malleolus of the foot.

3. Prone position: For patients who have been bedridden for a long time, if they lie in the prone position for a long time, pressure sores are likely to occur in the shoulders, anterior superior iliac spine, knee joints and other parts.

In order to avoid pressure sores, patients who are bedridden for a long time are advised to use air mattresses. They should also develop the habit of turning over regularly, preferably every 2 hours. After turning over, they should also massage the skin of the pressured area to promote local blood circulation and avoid pressure sores caused by prolonged local pressure.

| Manifestations of pressure sores at different stages

The specific manifestations of pressure sore staging are congestion and redness stage, inflammatory infiltration stage, superficial ulcer stage, necrotic ulcer stage, unclassifiable stage and deep tissue injury.

1. Congestion and ruddy stage. It may be manifested as localized erythema on the skin, which does not turn white when pressed with fingers, and is often located at the bony prominence. Most patients have darker skin, but the color of the pressure sore may be different from the surrounding skin. Compared with the adjacent tissues, this area may be accompanied by pain, hardness, tenderness to the touch, coolness or fever.

2. Inflammatory infiltration stage. Usually manifested as partial skin loss at the site of the pressure sore, open ulcers may appear in the superficial skin, there is no local slough, the wound surface is generally pink, and there may also be complete, open or damaged serous blisters and other symptoms. The appearance of local pressure sores is a translucent or dry superficial ulcer, and slough and bruises may also appear. For example, some patients have skin tears caused by medical tape, or dermatitis in the perineum causes local skin maceration and erosion, epidermal exfoliation, etc., which are symptoms of this stage.

3. Shallow ulcer stage. Usually the patient's skin is missing and subcutaneous fat is visible, but bones, tendons, muscle tissue, etc. are not exposed. Although slough can be seen, sinus tracts or undermining may occur, the bones and tendons at the pressure sore are generally not visible or cannot be directly touched.

4. Necrotic ulcer stage. Patients in the necrotic ulcer stage generally have full-thickness skin tissue loss, and may have exposed bones, tendons or muscles. Some areas of the wound base may be covered with slough, eschar, etc. If it extends to muscles, fascia, etc., the exposed bones or tendons can be directly seen or touched.

5. Unable to stage. Usually the depth is unknown. After the full layer of skin tissue is lost, there may be slough at the base of the wound, which is generally yellow, tan, gray, green or brown. There may also be eschar, which is tan, brown or black. The actual depth can be determined only if enough slough and eschar are removed to expose the base of the wound. Otherwise, it cannot be classified.

6. Deep tissue damage. Deep tissue damage is usually of unknown depth. In the intact and brown local skin, purple or maroon color changes or blood-filled blisters may appear. It is usually related to pressure and shear force on the skin surface, such as damage to the subcutaneous soft tissue. Compared with the adjacent tissues, this part will first experience pain, hardening, erosion, looseness, heat or coolness. It is basically difficult to identify deep tissue damage in individuals with dark skin.

| Classification of pressure ulcers

1. Yellow wounds of pressure sores. During the treatment of pressure sores, if the wound is found to be yellow, it means that the base of the wound is composed of desquamated cells and dead bacteria, which means that the wound may be infected.

2. Black wounds of pressure sores. If black necrotic tissue and black scabs appear at the wound of pressure sores, it means that venous blood return is seriously obstructed, local congestion leads to thrombosis, and tissue ischemia and hypoxia, and the disease is showing a trend of development.

3. Red wounds of pressure sores. If a red wound appears on the pressure sore, it means that the base is healthy red granulation tissue, which means that the wound is clean and healing.

| Measurement of Pressure Ulcers

There are many ways to measure wounds, which are affected by the workload, cost, and value of the results. The frequency of measurement is determined by the nature of the wound: chronic wounds should be measured 1 to 2 times a week or longer; acute wounds should be measured every 2 to 4 hours or every time the dressing is changed.

The size of the wound is expressed as length*width*depth, usually in cm or mm. The longest and widest parts are measured. Irregular wounds require multiple measurements. Use the head or 12 o'clock on the clock as a reference point, and use arrows to show the direction of the wound on the body. You can draw a picture to illustrate.

Different people may get different results when measuring, and irregular wounds may not reflect the true size of the wound. The shape and size of the wound will change as the wound develops, and necrotic tissue will mask the actual size of the wound. Monitoring the shape of the wound will also help choose the dressing.

1. Two-dimensional measurement of wounds

(1) Line measurement: The length and width are measured using the head or 12 o'clock as the reference point. The longest line along the longitudinal axis of the body is the length, and the widest line is the width.

(2) Wound description: used for measuring flat or shallow wounds. The material can be acetic acid paper or transparent plastic. The surface area of ​​the wound can be calculated and the size of the wound can be directly compared.

2. Three-dimensional measurement of wounds

(1) Line measurement: measurement of length, width, and height. The height of the wound is the depth perpendicular to the skin surface.

(2) Wound modeling: Use dental impressions of alginate or sponge dressings to model the wound volume. In fact, it is rarely used in daily work.

| Treatment of pressure sores

The treatment of pressure sores is divided into local treatment and general treatment, as follows:

1. Local treatment: First, a professional doctor needs to perform debridement. After debridement, new dressings (such as hydrocolloid dressings, alginate dressings, etc.) can be used on the pressure ulcer area to create the best wound healing environment. Topical recombinant human epidermal growth factor, compound tung leaf burn oil, mupirocin ointment and other drugs can also be used locally as prescribed by the doctor.

2. General treatment: (1) Patients need to maintain a good attitude and avoid tension and anxiety. (2) Turn over frequently, once every 2 hours, to avoid the sore surface contacting the bed surface and continuing to be under pressure. (3) Improve the overall nutritional status. It is recommended to eat a high-protein, high-vitamin diet. Those who cannot eat can follow the doctor's advice to supplement protein, amino acids, fresh plasma, etc. intravenously to enhance the body's resistance. (4) Actively treat the primary disease.

(Picture from the Internet)