Pressure ulcer

A decubitus ulcer is an area of local damage to the skin and underlying tissue. It is also called pressure sores, wound deck ulcer, or each - ulcer. Synonymous is also the name decubitus ( to Latin decumbo, lie down ').

Decubitus ulcers can be therapeutic errors and are therefore also seen as an indicator of quality of care.

Pressure ulcer classification by degree (Shea 1975) and stage ( Seiler 1979)

Decubitus ulcers are by J. D. Shea three stages divided into four grades, and after Walter O. Seiler:

  • Grade 1: not blanchable, circumscribed erythema of intact skin. Other clinical signs may be edema, induration, and local hyperthermia.
  • Grade 2: partial loss of the skin; Epidermis to the corium shares are damaged. The pressure loss is superficial and can clinically present as bladder, skin abrasion or shallow ulcer.
  • Grade 3: full thickness skin loss including damage or necrosis of subcutaneous tissue, down to, but not below, the underlying fascia can range. The pressure ulcer presents clinically as a deep, open sore.
  • Grade 4: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures such as tendons or joint capsules, with or without full thickness skin loss.
  • Stage A: wound " clean ", granulation tissue, no necrosis
  • Stage B: Wound greasy shows residual necroses, no infiltration of the surrounding tissue, granulation tissue, no necrosis
  • Stage C: wound as stage B with infiltration of surrounding tissues and / or general infection (sepsis)

Formation

The term pressure ulcer refers to local pressure load as a key development factor. The load can be assessed according to the formula: pressure × time. Crossing from the external pressure acting on the capillary vessels of the vessels, so there is trophic disturbances. This limit is often referred to in the literature as the physiological capillary. Usually already enough the weight of the respective ( stationary ) part of the body to exceed the capillary pressure. Various studies on the determination of which provided ( among other things, by E. M. Landis, K.-D. Neander, Yamada and Burton) values ​​32-70 mmHg for an interruption of the blood supply.

Takes a pressure load above the Kapillardruckschwelle on longer, there is an under-supply the cells with oxygen ( hypoxia) and nutrients. The oxygen partial pressure drops to 0 mmHg ( ischemia) and toxic (acid ) metabolites accumulate in itself. The necrotic tissue and nerve cells suffer irreversible damage. The increase of acid metabolites triggers a reflex in healthy people from rearrangement and thus relieving vulnerable skin before permanent damage occur. In elderly and sick people these reflexes are often only limited or non-existent, remains under the necessary relief of the fabric. As a result of acidification of the tissue is the body's vessels far ( vasodilatation ), so that these areas of skin are better supplied with blood - a lasting and compressive skin redness - Pressure ulcer grade I - is the result. As a particularly vulnerable points apply with less soft tissue coverage ( muscle or fat tissue) and outwardly curved (convex) bony abutments: the sacral region, the heels, the rolling hills of the femur and the ankle. Pressure can not be distributed enough here, since there is no subcutaneous fat.

The development of a pressure ulcer should be seen as multifactorial as a result of intrinsic and extrinsic risk factors. The intrinsic factors are " the patient himself " (reduced mobility, old age / senility, nutrition, dehydration, body weight, additional diseases, infections, urinary or fecal incontinence, sensory disturbances, ...) founded. The extrinsic factors are determined by the environment of the patient. They can be - in the best case - by mobilizing and appropriate aids and by proper rearrangement ( see also decubitus mattress) and consistently planned maintenance of the affected positively influence.

Another extrinsic factors that favor the formation of pressure ulcers, apply:

  • Shear forces lead to twisting of the blood vessels; trophic disturbances are the result. Especially in the elderly, in which a decrease in the water content of the skin leads to a loss of elasticity, it can come through shear forces and to a separation of whole skin layers from each other;
  • Friction leads to injury to the skin surface;
  • Temperatures in non-physiological ranges and high humidity lead to a softening ( maceration ) of the upper skin layer, which thereby becomes more susceptible to injury.

Furthermore, the following factors promote a pressure ulcer:

  • Fever → sweating and increased oxygen consumption
  • Urinary and fecal incontinence, in addition acidic pH
  • Obesity → pressure by more weight, increased sweating
  • Cachexia → lack of padding by a lack of subcutaneous fat
  • Paraplegia suggesting possible pressure points (especially on the buttocks ) is not noticed in time.
  • Other factors: congestive heart failure, diabetes mellitus, immune deficiency and poor general condition

Scoring systems have proven to be beneficial to assess the risk of pressure sores due to intrinsic factors. To do awards for different categories ( for example, mental condition, physical condition, agility, ...) points. Patients under a certain number of points shall be deemed at risk.

Doreen Norton developed the Norton scale in the early 1950s. The first inadequate and partly spongy formulated scale was expanded in 1985 to the modified Norton scale. In addition to the medley and Waterlow scale, emanating rather from specific patients receiving Introductions or care areas, is now used primarily in the U.S., the Braden scale, which introduces, among other things, the categories ' friction and shear 'and' sensory sentience ".

Open decubitus ulcers may be the portal of entry for pathogens that cause not only local infections. A Dekubitalläsion can therefore, for example, by scattering of pus herds through the bloodstream of a serious and even deadly circumstances sequelae such as pneumonia (pneumonia) or blood poisoning (sepsis) lead to.

Prevention

Prophylaxis consists in the

  • Avoid pressure points Outdoor storage or padding of predilection sites such as bony prominences points,
  • Alternate storage Helpless,
  • Spreading of wrinkles in clothes or documents
  • Correcting wrong and lying Katheter-/Sondenschläuche
  • Avoid tight clothing or shoes. Furthermore by
  • Circulation- stimulating massage to vulnerable parts of the body with intact skin (eg, root - care products, circulation- stimulating lotions) and
  • Timely supply with urinary or fecal incontinence because of the skin-irritating effect of the precipitates and

An improvement of the supply can be provided measurements of specific hazards in the context of scale, such as the Braden or Norton scale.

Tool for pressure ulcer prevention in addition to specific storage systems among others sheepskins or anti -decubitus skins from pure new wool, in addition to reduce the pressure relief, the shear forces on the skin and wick moisture well. Large clinical studies have shown a decrease of pressure ulcer cases when sheepskins are used in accordance with Australian standards. These skins are washable and hygienic problem in up to 95 ° C.

Do not disregard the psychological situation of the person concerned. They are for your own motivation, nutrition, mobilization, prevention stimulate etc rather through a holistic care concept. You should participate in social life and meet with other people, instead of the whole day to spend in bed or room.

Tissue (biology) Epidermis (skin) Sacrum Intrinsic and extrinsic properties Waterlow score Integrated Authority File
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