Executive Summary
Some diseases disable patients rendering them immobile. Furthermore, there are some illnesses that cause long-term commas that require patients to stay in bed for months or even for years. The period of immobility reduces blood flow and exerts pressure on certain parts of the body. According to 2004 statistics by Park-Lee (2009), 11% of all residents in nursing homes had developed pressure ulcers. Pressure sores particularly can become a significant medical problem when nosocomial infections are placed into consideration. The development of pressure sources within the geriatric population, terminally ill patients, and disabled persons pose a serious concern for the health care facility. The major objective for most hospitals and related health care facilities is to ensure that a patient is comfortable and free of pain during the period of recovery or before death. Furthermore, patients are more susceptible to further infections than the rest of the population. The risk factors associated with the development of pressure sores are far-reaching. In addition, the development of pressure sores may signify neglect, which is not a very good observation in any health or related institution. These aspects put pressure on the caregivers, hospitals, and the health care system. This is because apart from dealing with a particular illness, they are required to invent measures to prevent the development of pressure ulcers.
Introduction
Pressure ulcers occur when the skin or tissues below the skin undergo necrosis due to pressure applied on the skin and the tissue. The tissues get damaged due to a lack of enough blood supply because of the pressure. (NHS 2008). It, therefore, means that pressure sores occur in particular areas where the tissue has been forced between a hard surface and a bone causing the cells of the tissue to die. The cells die due to insufficient blood and nutrient supply and mechanical stress. This is the situation that occurs for patients or persons who are forced to stay immobile for a long period. (Mayo Clinic Staff 2010). Apart from the risk factors and apparent discomfort pressure sores cause, the National Health Service also spends a significant amount of money in preventing and treating the pressure sores (Bilhart 2006). According to a study conducted in the UK by Bennet (2004), it is estimated that the amount of money spent by health care towards the treatment of pressure ulcers between 1999 and 2000 was around £1.4 to 2.1 billion. This amount is comparable to the amount of money spent by health care towards the treatment of mental disorders. Therefore it is only obvious that such an area would provoke extensive medical research aimed at understanding the problem and coming up with curative and preventive measures. (Williams 2009). Understanding the medical aspects surrounding the causes and development of pressure sores is significant. This is because it may lead to the discovery of proper curative and preventive measures that will save the National Health Service, a significant amount of revenue that will prevent the development of risk factors associated with the sores, and relieve patients of adverse discomfort. Understanding the histological and pathological aspects of pressure sores is important towards understanding the genesis, development, and perhaps treatment of pressure sores and this research will be based on these aspects.
Literature Review
Apart from the elderly and the terminally ill patients, pressure sores according to Atiyeh (2005) affect the “Paraplegic and quadriplegic particularly those suffering from spinal cord injuries who are at a high risk of developing pressure ulceration.” Atiyeh outlines the differences and the severity of this type of pressure ulcer, in that they are more difficult to control and to treat and should therefore be approached from a different perspective. These findings present an additional problem when studying pressure sores because it becomes important to put these facts into consideration. Atiyeh also adds that pressure sores are caused by a combination of factors all of which lead to the development of the ulcer. According to shear, these factors include: “pressure, shear, friction, moisture, and poor nutrition. Revis (2010) substantiates the findings that pressure sores are caused by a combination of factors, but goes on to emphasize that “pressure leading to ischemia is the common pathway.” Revis continues to explain that tissues are capable of tolerating pressure or short periods of time; however when the pressure increases up to a level Revis refers to as “capillary filling pressure” which is approximated at 32mm Hg by Kirman (2010) ulceration becomes inevitable. Kirman in discussing the pathophysiology of pressure sores describes the development of the sores by outlining that initially “pressure is exerted on the skin, soft tissue, muscle, and bone, by the weight of an individual against the surface beneath.” He goes on to emphasize that it is when the pressure exerted exceeds capillary filling pressure (32mm Hg), that the necrosis of the tissues begins. He goes on to outline that other factors cited earlier such as lack of control of incontinence which provides moisture, tear, and shearing function to speed up the process of ulceration. Therefore, it is important that caregivers should provide extra attention to patients with incontinence, which is usually associated with paraplegia to ensure that they do not develop pressure ulcers.
Kirman explains that the first tissue to be affected during this process is the muscle tissues perhaps due to its dependence on oxygen. The skin which is much more resistant is affected afterward. Kirman writes that changes may occur within two hours of continual pressure upon the tissue and these changes may be irreversible. The underlying muscles are always damaged at a faster rate than the skin. It is for this reason that most pressure sores have the shape of an inverted cone. (Kirman 2010).
According to Kirman (2010), one of the most used methodologies in treating pressure sores, characterized by turning the patient over in order to restore blood flow does more damage than good. The process of restoring blood flow also referred to as reperfusion, may lead to the enlargement of the sore making the situation worse. Kirman continues to outline that the exact mechanism of reperfusion, which worsens the sores, but says that there is a possibility that reactive oxygen species are involved. According to Kirman, persons who are sound in terms of sense, mental, and mobility have reduced susceptibility to pressure sore because either consciously or unconsciously, they respond to increased pressure on part of the body by shifting pressure to another part. It is for this reason that persons who are unable to respond to increased pressure on a particular part of the body, either by shifting or by moving, have increased susceptibility to pressure sores. Pieper (2010) adds that persons with obesity are at a higher risk of getting pressure ulcers due to decreased blood supply to their adipose tissue.
Current Research
Initially, it was considered that turning a patient periodically, would reduce the chances of the patient developing pressure sores. However, with research further findings it was realized that some resulting factors such as reperfusion would only function to worsen the situation. This is because turning or relieving the pressure should be done in a timely manner and unless it is a function of the sensory system, there are chances that a caregiver would not exactly know when to turn the patient.
In research conducted by Theaker (2005) in a period of 18 months, it was established that pressure devices significantly reduced the susceptibility of patients to pressure sores. The study was conducted in a blind manner where after obtaining consent from concerned authorities, patients were chosen on the basis of whether they had high risks of getting pressure sores. High risk was defined as patients, who had all the factors leading to and promoting the development of sores. After consent from the relatives, the patients were given either of the two pressure devices. The pressure devices were: “Hill-Rom Duo mattress and the KCI TheraPulse bed”. (Theaker 2005). The KCI TheraPulse bed was the object of research while the Hill-Rom Duo used in the intensive care unit as the standard mattress acted as the control. KCI TherPulse consists of cells that are inflated and deflated at intervals of five and ten minutes and this reduces the pressure that is placed on the tissues due to the weight and the surface underneath. The result established that pressure devices were significant in reducing patients’ susceptibility to pressure sores. Current recommendations are geared towards prevention rather than treatment because treatment has already been termed as being expensive. (National Library of Medicine 1992).
Recommendations
Pressure sores according to the literature review, are mainly caused by immobility. Just like other diseases, preventive measures should be more emphasized, since treatment is very expensive and in some instances impossible. (Patient UK 2010). Furthermore, caregivers should also be advised on proper care and management of pressure sores once they have occurred. It is advisable that the intensive care unit utilize special beds for patients who are terminally ill. (DermNT NZ 2010). These beds have the capacity to deflate and inflate at intervals of five and ten minutes, thereby reducing the pressure that is exerted on the tissues by the underlying surface and the weight of the body. Moisture can be caused by sweat and incontinence. Therefore patients who are bedridden and cannot move freely should be frequently checked on and their sheets changed to prevent the accumulation of moisture between the skin and the underlying surface. Caregivers should also watch out for early symptoms of pressure sores so that preventive measures can be taken. The symptoms include redness on the skin, cracks on the skin, and increased itchiness on the skin. In situations where pressure sores have already occurred, caregivers should take appropriate steps to avoid infection of the ulcers and further development of the ulcers. Infections can cause serious complications because some organisms may enter the circulatory system and infect internal organs, or release toxins that interfere with the physiological processes of the body. Infections can be prevented by treating the ulcers with saline solution and periodically changing the dressings. (Wilhelmi 2010)
Discussion
Pressure ulcers develop when undue pressure is placed upon the skin and underlying tissues. The sores appear like an open wound with the shape of an inverted cone, signifying tissue necrosis. Pressure sores are a major source of problems for caregivers, health care, and patients. Caregivers are burdened with the need to check on patients frequently for any signs of pressure sores and to take preventive measures such as turning the patient periodically. The health care system is also burdened with the need to treat the pressure sores that have already occurred, some of which require surgical procedures. Furthermore, pressure sores may also lead to infections that may require additional treatment of the patients. Pressure sores also cause discomfort, pain, and perhaps additional medication to the patient. Researchers have managed to demystify the etiology of pressure sores and it has become apparent that prevention is currently the best measure. (Salcido 2009)
Conclusion
Pressure sores are caused when capillary filling pressure exceeds 32mmHg. This mostly occurs when a person having reduced or total lack of mobility exerts pressure on tissues due to the underlying surface and the weight of the body. Pressure sores are not only costly to the health care system but also to health institutions. (Chacon 2010). Currently, preventive measured are recommended because treatment is very expensive. Pressure sores occur mostly among the aged, paraplegic and quadriplegic, and acutely ill patients. However, there are some differences between pressure sores in quadriplegic and paraplegic and pressure sores in the aged. Pressure ulcers are also not just restricted to patients who stay in bed for long periods, or the paraplegics who are unable to respond to signals to move position to alter the pressure. Pressure ulcers can also develop in persons who are obese due to the lack of enough blood supply to their adipose tissues. Furthermore, persons who are diabetic and persons who smoke are at a higher risk of developing pressure ulcers. Pressure sores have become a major concern for caregivers, patients, and the health care system in general. Perhaps further research should be conducted in the area to come up with more effective preventive measures.
References
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DermNet NZ (2010) Bed Sores. DermNet NZ Journal. Web.
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National Library of Medicine (1992) Pressure Ulcers in Adults: Prediction and Prevention. AHCPR, 92. Web.
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Pieper, B. (2010) Pressure Ulcers Prevention and Treatment: Implication for the Person with Obesity. Ostomy Wound management Journal, 53 (3). Web.
Revis, D.R (2010) Decubitus Ulcers. MedScape Journal. Web.
Salcido, R. & Popescu, A. (2009) Pressure Ulcers and Wound Care. MedScape Journal. Web.
Theaker C., (2005) Pressure Ulcer Prevention in Intensive Care: A Randomized Controlled Trial of Two Pressure Relieving Devices. PubMed Journal, 61(6). Web.
Wilhelmi, B.J. (2010) Pressure Ulcers: Surgical Treatment and Principles. MedScape Journal. Web.