Pressure ulcers (decubitus)

The common clinical picture of pressure ulcers (decubitus, decubital ulcer) can be described as damage to the skin and underlying tissue. The areas most commonly affected by pressure sores include the buttocks and heel. It is estimated that one in 10 to 30 hospital patients suffers from pressure ulcers.

However, the rate of pressure ulcer sufferers in nursing homes is even higher. Here, an average of 45 out of 100 patients are probably affected.

As pressure ulcer treatment is very costly (50,000 euros on average or 1 to 2 billion euros a year according to the German Institute for Innovation in Health Care and Applied Care Research) and the disease is an extremely painful and unpleasant condition for the patient, it is important to avoid it.

If too much pressure is exerted on the underlying tissue, this can lead to the appearance of pressure ulcers. Decisive factors for the occurrence of pressure ulcers are also specific risk factors of the patient, as well as the duration of high pressure on the tissue.

If the pressure exceeds a certain value, blood vessels may be compressed and die as a result of oxygen and nutrient deficiency.

Lying and sitting:

The risk of developing pressure sores is particularly high if there is very limited mobility, i.e. patients can only sit or lie down for a long period of time. This risk group includes above all elderly people who are confined to bed due to acute or chronic illnesses, or people who are dependent on a wheelchair. It can also frequently affect diabetics, who are less sensitive to external pressure and do not perceive it to the appropriate extent.

Pressure sores are particularly common in areas where more pressure is applied to the tissues. These include, above all, areas where there is little fat and muscle tissue, and thus the bones are not protected. Sites where bones are located directly under the skin include the buttocks, the large trochanters on the outer side of the thigh, and the heels, with the heels and buttocks being the most common sites of origin. However, unusual sites of origin may also be considered, depending on the patient's position or sitting posture. These include the ears, the back of the head, the shoulder blades, and the toes.

In rare cases, pressure ulcers can occur when the patient is in the prone position, during surgery for example. In this case, the knees, face, pubic area, and tops of the feet are the primary areas at risk for developing a pressure ulcer.

If a patient is confined to a wheelchair, for example after paraplegia, pressure ulcers are more likely to develop in the heel, buttock, toe or knee areas.

Blood supply and drainage are impaired:

Another problem is the interrupted blood supply and the reduced outflow via venous blood vessels due to the increased pressure. This condition causes an increase in acid metabolites in the tissue, which triggers a natural reflex in healthy people: movement relieves the affected part of the body, as a result of which the pressure decreases and normal blood flow to the tissue is restored.

However, if a person moves insufficiently, as is the case with bedridden patients, an accumulation of acidic metabolic products and an associated dilatation of the small arterial blood vessels occurs. The result is reddening of the skin, which is supplied with more blood due to the widening of the vessels. As a further phenomenon, fluid leaks from the blood vessels into the surrounding tissue. This results in a swelling of the tissue, in which water accumulates between the cells. Furthermore, it can be observed that blisters form and the tissue is thus more extensively destroyed.

Thin, inelastic skin:

Since pressure ulcers mostly affect older people whose skin loses elasticity and tightness over time, "sliding around in bed" can cause abrasion of the usually thin skin. This can result in the separation of entire layers of skin.

Further decisive factors for the development of a decubitus are the nutritional condition and the age of the patient, as well as the cause of the bed confinement. If the skin is already damaged by previous illnesses, as is often the case with diabetics, for example, a pressure sore can develop in less than 2 hours. If patients have less protective fat, the bone is also exposed to higher pressure.

Another cause of development is reduced control over urine or stool and the associated constant dampness in the area of the anus or vagina. Because moist skin softens more quickly, a pressure ulcer is more easily formed. Painkillers and other medications can also increase the risk of a pressure ulcer.

The severity of decubitus can be divided into 4 degrees and is assessed on the basis of changes in the skin.

At the beginning (stage I) there is a reddening of the affected skin area that does not disappear. The redness, which is a precisely defined area, does not disappear even when the pressure on the tissue is relieved. In some cases, a hardening and warming of the skin is noticeable, but the skin is still in an intact state.

If the pressure persists, however, stage II occurs. This is characterized by blistering of the skin and abrasion of the uppermost skin layer. The resulting wound, although open, is still superficial.

In stage III, the pressure ulcer already reaches into the muscles and forms a deep, open ulcer.

If the ulcer reaches stage IV, exposed bone can be seen. Destruction of the skin, muscles, bones, joints and tendons occurs.

In order to prevent a pressure ulcer, it is essential to regularly check the areas in question in people at risk, as a pressure ulcer is easily visible to the naked eye. Unfortunately, as regular monitoring does not always take place, pressure ulcers are often not detected until stage III.

To reduce the risk of a pressure ulcer, some patients, such as wheelchair users, may use a mirror to examine hard-to-see areas. Another option is to ask family and friends for help.

If there is a risk of developing a pressure sore, it is advisable to keep an eye on the area at risk and check it regularly. In a hospital or nursing home, this is the responsibility of the nursing staff to detect any pressure sores early.

To detect a pressure sore, a simple method can help: the finger test. In this test, the patient's skin, which is reddened in a certain area, is pressed. If the redness does not subside, it can already be assumed that a stage I decubitus is present.

In general, the earlier a pressure ulcer is detected by doctors or nursing staff, the more effectively it can be treated. A two-part therapy is then usually applied. On the one hand, the doctor applies a local therapy, and on the other hand, a causal therapy is used to treat the factors that cause the pressure sore.

Local therapy:

The purpose of this therapy is to remove dead tissue (debridement). This can be done either surgically with the help of a scalpel (surgical depridement), or by using enzymes (enzymatic depridement) or fly larvae (biosurgical depridement, maggot therapy). If necessary, the wound is disinfected and treated with moisture, for which various wound dressings are available.

In some cases, technical treatment methods are needed, such as the vacuum sealing technique (VAC system).

Causal therapy:

To permanently prevent a pressure ulcer, the pressure points at risk must be relieved. For this purpose, the patient must be appropriately positioned with the aid of special decubitus mattresses or special beds and regularly repositioned.

In order to prevent a reduction of the protective fat cushions, an appropriate diet is important, in which the patient is supplied with sufficient calories, as well as protein, vitamins and minerals. A special diet can also help here. Pain medication can also be used if necessary. Regular exercise as part of physiotherapy or by the nursing staff prevents one-sided strain on a particular area of the skin and improves circulation. In order to create an all-round sense of well-being for the patient, it is important that concomitant diseases are treated and that the patient is psychologically well and depression is prevented.

If the pressure ulcer is still classified as stage I-III, conservative therapy is usually sufficient and no surgery is necessary. However, if stage IV occurs, surgical intervention is often unavoidable, in which the ulcer and occasionally also part of the bone is removed.

In order to give a prognosis for a pressure ulcer, it is necessary to take into account how well the treatment goes and what concomitant diseases the patient also suffers from.

As already mentioned, the likelihood of healing also depends on the stage at which the pressure ulcer is detected. The earlier a pressure ulcer is diagnosed, the higher the chance of healing and the faster the healing process. If risks for poor wound healing such as diabetes are also reduced, pressure ulcers heal very quickly.

Since pressure ulcers often cause great pain and restrictions in everyday life as well as in leisure time, many patients withdraw and can sometimes develop depression. These are a great burden for anyone affected, not least because it takes a very long time for them to be treated or successfully treated.

In order to prevent a pressure ulcer from the outset, it is important to know the risks and to assess them individually for each patient. These include the patient's mobility and activity level, as well as their ability to respond to pressure discomfort. In addition, the nutritional status of the patient, the moisture of the skin and the shear forces on the skin must also be assessed. In order to take all the above factors into account, nursing homes use certain documentation forms, such as the Braden scale. Here, points from 1 to 4 are assigned for certain risk factors and added up at the end. If the result is 18 or less, there is no risk of pressure ulcers, but if the value is less than 9, the patient has a very high risk of pressure ulcers.

Preventive measures:

To prevent pressure sores, several points must be considered:

• Correct positioning on certain mattresses and regular repositioning are important to avoid pressure sores.
• Frequent movement exercises and mobilisation with the support of nursing staff and/or physiotherapists
• Promoting the patient's "mental mobility" by reading, listening to the radio, watching television, talking to others
• For patients at risk, it is advisable to use a special mattress that ensures that the pressure on a specific body surface is distributed over a larger contact surface. Modern mattresses have an integrated motor that constantly changes and controls the pressure in the mattress.
• With the help of MiS Micro-Stimulation, an attempt is made to give the patient more body sensation through a kind of electrically controlled mattress. This is achieved by touching and small movements, which encourage the patient to move independently.
• Skin care appropriate to the patient's skin type
• Risk factors, such as skin condition, can be improved by a balanced diet. Important here are above all sufficient calories, protein, vitamins and trace elements.
• Underlying and concomitant diseases must be treated primarily