Pressure Injuries: Etiology, Pathophysiology, Evaluation, and Interprofessional Treatment
Pressure injuries, also known as pressure ulcers, decubitus ulcers or bedsores, are skin and soft tissue injuries caused by prolonged pressure on specific areas of the body. Understanding the role of the skin and its functions, including pressure-induced vasodilation, is essential in comprehending the pathophysiology of pressure ulcers. This article reviews the etiological factors leading to pressure ulcers, various medical conditions associated with their development, and the complications that can arise from these injuries. The article outlines treatment options based on the stage and severity of pressure ulcers and emphasizes the importance of an interprofessional approach for optimizing patient care and outcomes. Additionally, we explore the use of active mattresses as a valuable intervention in preventing pressure ulcers and enhancing patient comfort during treatment by stimulating pressure-induced vasodilation and improving endothelial function.
The skin, as the body's largest organ, plays a crucial role in protecting the underlying tissues and maintaining homeostasis. Pressure ulcers, also termed decubitus ulcers or bedsores, are skin and soft tissue injuries resulting from prolonged pressure on specific bony areas of the body. To comprehend the pathophysiology of pressure ulcers, it is vital to understand the skin's functions, including its response to pressure-induced vasodilation. Pressure-induced vasodilation is a physiological response that improves blood flow to the skin and enhances skin health and function, reducing the risk of pressure injuries. This article aims to provide an overview of the etiology, pathophysiology, evaluation, and interprofessional treatment options for pressure ulcers, along with a focus on the role of active mattresses in prevention and care.
The development of pressure ulcers is multifactorial, involving external and internal factors. Key causes include loss of sensory perception, impaired consciousness, and decreased mobility, leading to prolonged pressure on tissues. Both external factors (pressure, friction, shear force, and moisture) and internal factors (fever, malnutrition, anemia, and endothelial dysfunction) contribute to ulcer formation. Even a brief period of immobility in bedridden or surgical patients can initiate the process of ulcer formation. Neurologic and cardiovascular diseases, prolonged anesthesia, dehydration, malnutrition, hypotension, and surgical conditions can predispose individuals to pressure ulcers.
Pressure ulcers pose a significant healthcare problem globally, affecting thousands of individuals each year. Managing these ulcers incurs substantial costs, straining healthcare economies. Elderly patients, especially those over 70 years old, are at higher risk of developing sacral decubitus ulcers. Hospitalized patients are also susceptible, with a substantial number of ulcers developing within five days of admission. Intensive care unit (ICU) patients are particularly prone to pressure ulcer development.
The skin functions as a barrier, protecting the underlying tissues from external insults and pathogens. When exposed to short periods of low to moderate pressure, the skin responds with pressure induced vasodilation, increasing blood flow to the affected area to supply oxygen and nutrients. Pressure-induced vasodilation is a crucial mechanism that helps in redistributing pressure on the skin and enhancing blood flow, promoting skin health and reducing the risk of pressure injuries. Pressure-induced vasodilation (PIV) occurs naturally throughout the period of bed rest, as the act of repositining causes PIV. However, prolonged pressure can disrupt this process, leading to ischemia and subsequent tissue damage.
Histological studies of pressure ulcers reveal different stages, including blanchable erythema, non-blanchable erythema, decubitus dermatitis, decubitus ulcer, and black scab/gangrene. The initial change occurs in the vessels of the papillary dermis, followed by necrosis of skin structures. Chronic pressure ulcers show densely aggregated bacterial colonies, while acutely developed ulcers do not exhibit such findings.
The evaluation of pressure ulcers involves gathering a detailed history, including immobility duration, hospital stay, associated medical conditions, and natural history of the ulcer. Physical examination is essential to stage the ulcer, assess size, sinus tracts, undermining, drainage, necrotic tissue, and associated pain. Evaluation should be comprehensive to guide appropriate management.
The prognosis for pressure ulcers varies based on the treatment regimen. Some studies show pressure ulcer healing rates as high as 53% within 42 days with specific treatments, while others indicate that complete healing is challenging to achieve. Lifelong treatment and prevention measures are typically necessary, and recurrence rates are high.
Treatment / Management:
Treatment of pressure ulcers varies based on site, stage, and associated complications. Prevention remains the best approach, utilizing excellent skincare, support surfaces and frequent repositioning to create PIV. Support surfaces, such as active mattresses that mimic natural repositioning of healthy humans, have been shown to reduce incidence of pressure ulcers.. Research has shown that Squirrel Vestims active mattresses can significantly improve PIV and enhance endothelial function by +197% following 8 weeks of use. This improvement in endothelial function leads to blood vessel remodeling and improved blood flow to the skin, enhancing skin health and reducing the risk of pressure injuries. Repositioning every two hours is crucial, and some patients may require more frequent shifts. Hydrocolloid dressings and antibiotic cover aid wound healing and reduce septicemia risk. Surgical management may be necessary for deeper ulcers, involving thorough cleaning, debridement, and flap reconstruction. Hyperbaric oxygen therapy may aid wound healing through improved oxygenation.
Complications & Care
Complications of pressure ulcers include infection, septicemia, catabolic effects leading to fluid and protein loss, chronic anemia or secondary amyloidosis, and postoperative complications following reconstructive surgery.
Postoperative and Rehabilitation Care:
Postoperative care is crucial for patients who undergo reconstructive surgery for pressure ulcers. Patients must avoid excessive shearing and stretching on skin flaps, and their positions should be regularly monitored to prevent complications. Meticulous skin care is necessary to ensure optimal healing.
The management of pressure ulcers requires an interprofessional team, including primary care providers, wound care specialists, surgeons, internal medicine specialists, physical therapists, nurses, and aides. Collaboration among team members enhances patient care and improves outcomes.
Patients and their families should receive education on preventing pressure ulcers, including regular repositioning, using support surfaces, maintaining a healthy diet, and recognizing warning signs of ulcer development.
Pressure ulcers are a significant healthcare concern that requires prompt and effective treatment to prevent fatal complications. An interprofessional approach involving various healthcare specialists is essential to provide optimal patient care and improve outcomes. Preventive measures, adequate evaluation, and appropriate treatment options, including the use of active mattresses, are crucial in managing pressure ulcers effectively and promoting skin health through pressure-induced vasodilation.
Further research and collaboration among healthcare professionals will aid in better understanding and management of these challenging conditions.
Squirrel Mattress Improves Skin Function.
A well-maintained and functioning epidermis greatly reduces the risk of pressure injuries, emphasizing the paramount importance of skin health and functionality in mitigating pressure ulcer formation. The groundbreaking research undertaken by the University of St Mark and St John, England, demonstrated that 8 weeks use of Squirrel Vestim's active mattress lead to a significant ENHANCEMENT OF BOTH SKIN HEALTH AND FUNCTION (1), thus serving as a crucial tool in pressure ulcer prevention.
(1) Skin Tissue Results
Following 8 weeks use of the Squirrel Vestims® MRS mattress, participants experienced clinically significant improvements in skin health and function, including ...
- Endothelial Function IMPROVED +197% (p=0.021)
- Resting Blood Flow IMPROVED +336% (p=0.003)
Research conducted by University of St Mark and St John, England.
Pub Med References.
(1) Baker G, Bloxham S, Laden J, Gush R. Vascular endothelial function is improved after active mattress use. J Wound Care. 2019 Oct 2;28(10):676-682. doi: 10.12968/jowc.2019.28.10.676.
Pub Med ID. 31600104.