Pressure ulcers or pressure sores are commonly seen among the sick and debilitated individuals admitted to nursing homes with prolonged immobility.
Evaluation of the patient’s skin for signs of pressure sores is vital. Pressure sores are notoriously recurrent and difficult to treat. Their most important management is by prevention of occurrence in the first place.
Diagnosis on admission to hospital
On admission to the acute or chronic care hospital all patients need a thorough skin assessment to determine if they may develop pressure ulcers or if they have symptoms of early pressure ulcers. (1-5)
Evaluation involves presence of previous ulcers, assessment of risk of pressure ulcer development.
Assessment of skin is done using various tools and the commonest one that is used is the Braden scale.
The scale rates all factors between 1 to 4, with the exception of friction and shear, which only has three points on its scale. The score is then added up.
This tool checks the following:
- Sensory parameters or sensation over the skin
- Moisture present of the skin
- Activity of the patient irrespective of his or her degree of mobility
- Mobility that assesses if the patient can change and control his or her body posture and position
- Nutritional assessment
- Assessment of friction forces and shearing forces over the affected skin.
The highest possible Braden score is 23. Patients with scores of 18 or less are considered to be at risk of pressure sores.
Special care is taken to prevent pressure sores and related skin changes among those at risk.
Assessment of those with pressure ulcers
In patients presenting with pressure ulcers the ulcer is documented using photographic evidence. Patient’s general health and nutritional status is assessed.
Mobility, previous pressure damage, level of consciousness, psychological factors etc. are also assessed.
The patient undergoes a routine blood test to detect infections, high blood sugar (diabetes), high blood cholesterol) and sometimes blood cultures to determine presence of infections.
Blood cultures are prescribed if there are signs of severe blood poisoning like fever, elevated white blood cell count, rigors, sweating and delirium.
Nutritional assessment is made by testing for serum albumin and haemoglobin (to detect anemia). A routine chest X ray is performed before any surgical treatment is chosen.
Evaluation of pressure ulcers
The ulcer is evaluated by looking at:
- Cause of the ulcer – diseases like diabetes, kidney disease anemia etc. are diagnosed
- The location of the ulcer is evaluated and all pressure spots are closely examined
- Dimensions of ulcer are marked by photographic evidence using a calibrated ruler
Evaluation of type of discharge and pus
Amount and type of discharge and pus is noted. This is assessed along with signs of infection.
A swap is used to take a sample of the pus or exudate and this is placed on a glass slide. This is evaluated after staining with appropriate dyes and examining under the microscope for presence of microorganisms.
The samples of the exudate is also used for culture in the laboratory and assessment of sensitivity to various antibiotics that may be used in therapy.
Presence of a track of pus or fistula or sinus is noted. This is usually a recurrent and bothersome condition that is difficult to treat without surgery.
Staging of pressure ulcers
The ulcer is staged as per its depth. Staging does not depend on the total area of the ulcer. A stage I or II pressure ulcer may have a large surface area, but a stage III or IV is usually of relatively smaller diameter but of greater depth.
Stages are progressive and need regular assessment and early management.
- Stage 1 - There is a change in color of the skin that may turn redder or darker and may not blanch on application of pressure with a gloved finger. The skin feels warmer than that of the surrounding skin. In some cases the skin may appear normal and only an examination determines abnormality.
- Stage 2 - In this stage there is break in the outer epidermal layer of skin and some invasion within the next layer – the dermis. These show up as shallow craters, ulcers, blisters or abrasions. The blisters may be filled with a clear or cloudy fluid.
- Stage 3 - These extend into the subcutaneous tissue and gape as open wounds. Underlying bone, muscle, and tissues are visible but these structures are not affected. There may be formation of tunnels of damage in this stage.
- Stage 4 - These ulcers affect the underlying bones and muscles as well as joints, tendons and nerves.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)