How are Pressure Ulcers Treated and How to Prevent Skin Breakdown

An estimated 15 per cent of acute care patients have pressure ulcers. In recent years, the incidence of pressure ulcers has increased by 63 per cent, with a high prevalence being noted among patients in nursing homes, hospitalized patients, and patients with spinal cord injuries. The Agency for Healthcare Research and Quality estimates the cost of pressure ulcers at $9.1 to $11.6 billion a year in the United States. The high cost of wound care notwithstanding, lawsuits related to pressure ulcers are the second most common claim after wrongful death.  A pressure ulcer, also known as a bed sore, pressure sore or decubitus ulcer, is an injury to the skin characterized by redness and breakage caused due to constant friction or pressure. It can be painful, difficult to treat, and lead to serious life-threatening consequences.

Depending on the grade of the pressure ulcer – which can range from skin discoloration to damage to the skin patch and underlying structures – different treatments can be prescribed. Treatment is less challenging in the early stages, while later stages may necessitate surgery or aggressive treatments, and require longer recovery times.

Pressure removal or redistribution

Patients who are required to stay in bed for long periods of time are at a risk of friction injury and skin breakdown. They may be made to lie on pressure-relieving mattresses placed on top of regular mattresses. The mattresses can be made of gel, foam or filled with air or water. Small gel cushions are also available for wheelchairs.

Essentially, the job of pressure removal or redistribution products is to remove or spread out pressure from different parts of the body. For instance:

• Heel booties and elbow pads  to prevent skin from rubbing against surfaces
• Footboards positioned upright at the foot of the bed to maintain the patient's feet flat against the headboard and keep them aligned properly
• The pressure of top sheets and blankets can sometimes set off the skin breakdown process. A bed cradle is used to keep the blanket or bedspread away from the patient's feet while still covering the upper half of his/her body.
• An alternating pressure bed alternates the deflation and inflation of air cells to change pressure points constantly throughout the body. It also promotes blood flow to the skin and underlying tissues to prevent the formation of decubitus ulcers.
• An airflow bed is infused with tiny beads and a fabric cover. An air current keeps the beads in constant motion, creating an effect similar to fluid – like a waterbed – to help alleviate pressure at pressure points. The patient's skin is also kept dry by the circulating air.
• A wedge turning frame is another equipment that makes it easy to reposition patients with severe burns or spinal injuries.

Depending on the patient's condition and care plan, appropriate pressure reducing devices may be recommended.

Barrier creams

Skin breakdown is attributed to four main factors: moisture, skin pH, friction, and colonization with microorganisms. Moisture, friction, shear and interface pressure can hasten pressure damage and result in ulceration. Moisture is a common factor – whether the skin become moist from sweat or incontinence – which can break down the outer layer of the skin and increase risk of damage.

A good skin care regimen is essential in patients with urine or fecal incontinence. As far as moisture protection is concerned, barrier creams, ointments or gels can avoid excessive moisture build-up on skin. The barrier cream must be moisturizing, breathable and hypoallergenic, easy to apply and remove, suitable for use on injured and intact skin, and adhere to dry as well as moist skin. Additionally, it must be comfortable and compatible with incontinence bed pads.

Nurses administering skincare regimen to patients must be knowledgeable about the potential irritants in barrier creams to avoid adverse reactions or catch them early on. Studies have indicated that silicone-based barriers offer better protection compared to other barrier treatments, and are also more comfortable than alcohol-based products that often cause discomfort to patients.

Potential irritants include benzyl alcohol, beeswax, edetic acid, polysorbates, fragrances, butylated hydroxyanisole, butylated hydroxytoluene, sodium metabisulphate, sorbic acid, isopropyl palmitate and cetostearyl alcohol.

Perineal care

Patients with urine or feces incontinence issues must be provided quality perineal care. Feces and urine can irritate the skin and lead to its breakdown. Fecal incontinence can be more damaging than urinary incontinence as the enzymes in feces are more active and destructive in an alkaline environment and can distress the skin significantly. Proactive perineal care keeps the skin dry and clean, which is necessary to prevent skin breakdown.

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The Role of Nutrition

Randomized control trials have concluded that optimum nutritional support may be beneficial for patients at a risk of developing pressure ulcers. How exactly nutritional support assists ulcer prevention is yet to be ascertained. It could be that an enhanced nutritional status combined with weight gain can increase soft tissue cushioning over bony prominences, which can distribute pressure over a broader area.

Protein, arginine and micronutrients contribute significantly to the wound healing process. Quite a few recent studies in this area have revolved around the role of arginine in particular. The semi-essential amino acid which assists with blood flow and nitric oxide levels has been found to possess beneficial pharmacologic effects. Its vasodilatory and anti-bacterial properties are important to wound healing.

In this regard, nutritional supplementation can be delivered through Arginaid, an l-arginine intensive drink that may enhance protein metabolism, limit muscle loss and promote collagen synthesis to increase the strength of the wound.

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