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Pressure sores, also known as bed sores and pressure ulcers, are quick to develop but can take a long time to heal. They can be debilitating, extremely painful and, if left untreated, could be fatal. However, with proper nursing care they can also be prevented. Pressure sores as a result of medical negligence are, unfortunately, all too common.

Causes of pressure sores

Pressure sores occur as a direct result of unrelieved pressure and distortion of the skin and underlying tissue.

The extra pressure disrupts the flow of blood through to the skin and, without adequate blood flow, the area of skin becomes starved of oxygen and nutrients. The skin can then begin to break down and an ulcer forms.

People with health conditions which limit their mobility are most at risk of developing pressure sores. The elderly can often be at risk of developing sores due to a lack of mobility, and so pressure sores occur in care homes as well as in hospital.

Grades of pressure sores

Pressure sores are divided into four different grades, depending on the severity of the sore:

  • Grade 1: Discolouration of the skin.
  • Grade 2: Partial thickness skin loss, presents like a blister.
  • Grade 3: Full thickness skin loss, but damage of subcutaneous tissue, presents like a deep crater.
  • Grade 4: Full thickness skin loss with extensive necrosis extending to the underlying tissue.

Prevention of pressure sores

Pressure sores can be easily prevented through good nursing care. Every patient who has or is going to have reduced mobility should undergo an assessment, whether in hospital or a care home.

Pressure sore treatment

By risk assessing patients then putting in place appropriate care plans the risk of pressure sores developing is reduced, and could mean that they do not develop at all.

It should be realised that sometimes (despite a high level of nursing care) some patients will still develop pressure sores due to irreversible tissue hypoxia (where the tissue is deprived of adequate oxygen). However, in our experience, most of our clients have developed pressure sores in situations where they could have been prevented.

Once a pressure sore has been identified, a further assessment of the patient should be undertaken, and a revised repositioning plan put into place to avoid the sore worsening.

What is a pressure sore?

A pressure sore or  bed sore  is an area of damaged skin that becomes an open wound.

What causes a pressure sore?

Pressure sores begin when the weight of your body presses down on the skin beneath you. Your blood cannot circulate properly to that area, and so skin cells break down and die.

The best way to describe how a pressure sore develops is to look at what happens to an orange in a fruit bowl which is not moved for a long period of time. The part of the orange in contact with the fruit bowl (i.e. where the pressure is) becomes mouldy and starts to decay. The same happens with the human body.

Who can get a pressure sore?

People of any age can be affected by bed sores or  pressure ulcers  . In particular, people with poor mobility who have to spend long periods of time in bed or sat in a chair are at greater risk of a sore developing. People who are unable to change their position are also at higher risk.

Pressure sores often affect patients in hospital but can also affect people who live in care homes.

Pressure sores can also develop as a result of poor nutrition, anaemia, recurrent infection and poor circulation.

There is a tendency to assume that pressure sores are the inevitable result of prolonged bed-rest. This is not necessarily the case.

How do I spot a pressure sore?

The first sign that a pressure sore might be forming is a change in the colour of the skin. This can then get progressively worse and can lead to an open wound.

Where do pressure sores occur?

The most common places for pressure sores are over the bones that are close to the skin, like the bottom, heel, elbow, ankle, shoulder, back and back of the ear.

Are there risk factors associated with pressure sores?

There are a number of risk factors associated with pressure or bed sores, such as:

  • Lack of mobility/inability to reposition  – could lead to excessive pressure in one location.
  • Dehydration and poor nutrition  – can affect the body’s ability to maintain healthy skin and prevent breakdown of skin tissue.
  • Age  – as people get older, the skin becomes more fragile and new skin cells take longer to form.
  • Lack of sensory perception  – people in a coma or suffering from a serious spinal injury may not be able to feel pain as a sore develops, and they are not therefore aware of the need to change position.
  • Weight loss  – significant weight loss can result in less cushioning between the bone and for example, a bed, making it more likely a sore will develop.
  • Urinary/faecal incontinence  – the skin is more moist, causing it to break down more easily.
  • Medical conditions affecting circulation  – can cause the same issues as being unable to reposition yourself regularly, as the circulation to the skin is affected.

What is a Waterlow assessment?

This is a risk assessment tool, used by nurses/carers to assess which patients are most likely to develop a pressure sore or ulcer.

Simply, the person undertaking the assessment reviews a chart that details all of the factors that might contribute to a pressure sore developing (e.g. build, weight, height, continence, mobility and whether someone has undergone major surgery recently).

Each factor is awarded a numerical value depending on the relevance of the risk factor and, once a final score is calculated, it is supposed to reflect the degree of risk the patient has of developing a pressure ulcer. It was developed in 1987 by Judy Waterlow, and is used throughout hospitals and nursing homes.

Can bed sores be prevented?

In most cases, the answer is yes. The most important factor in preventing sores is to avoid prolonged periods of pressure on any one area of the skin. This can be achieved by encouraging a person to change their position regularly throughout the day.

People who cannot reposition themselves should be moved at regular intervals and at least every two hours for those lying down and every hour for those sitting upright.

Special air filled alternating pressure mattresses and cushions that redistribute pressure help reduce pressure on sensitive areas.

Regular inspection of high risk pressure areas is important to detect early signs and prompt medical care should be provided.

It is also important to keep skin healthy, clean and dry.

What are the NICE guidelines relating to pressure sores?

NICE is the National Institute of Clinical Excellence.

In 2005, NICE issued guidance on the prevention and treatment of pressure sores, following a collaborative review with the Royal College of Nursing. The guideline gives guidance on the management of pressure sores in both primary and secondary care.

The key priorities identified in the guidance are:

  1. Patient should have an initial & ongoing risk assessment within the first 6 hours of care;
  2. The ulcer grade should be recorded using the standard classification system;
  3. There should be an initial and an ongoing pressure ulcer assessment, supported by photos and diagrams if appropriate;
  4. People vulnerable to pressure ulcers should be placed on a high spec foam theatre mattress;
  5. If a patient is having surgery, they should as a minimum be placed on a foam mattress;
  6. For Grade 1-2 ulcers, patient must be placed on a pressure reducing mattress and closely observed for skin changes;
  7. For Grade 3-4 ulcers, patient must be placed on a foam mattress with an alternating pressure relieving overlay or be placed on a continuous low pressure system.

How can you tell if a pressure sore is healing?

As a pressure sore heals, it will slowly get smaller. Less fluid will drain from it and new healthy skin starts growing at the bottom of the sore. This new skin is light red or pink and looks lumpy and shiny.

How do you treat a pressure sore?

It is essential is that the sores do not become infected.

For those who suffer less severe pressure sores, they can be successfully treated by trying to relieve the pressure on them using equipment like a  pressure relieving overlay system  mattress, cleaning the affected area regularly and applying an appropriate dressing. The wound should be kept clean and moist and the area around it clean and dry.

For more serious pressure sores a procedure called  debridement  , where dead tissue and other materials are removed from the wound, may be necessary.

In even more severe cases skin grafts, cosmetic surgery or maggot therapy may be necessary.  Maggot therapy  is a carefully controlled practice whereby a medical professional will try and use maggots to break down and ingest infected or necrotic tissue. As well as getting rid of the infected tissue the maggots also disinfect the wound by killing bacteria and can stimulate wound healing.

What are the consequences of pressure sores?

Serious pressure sores can be very painful and difficult to heal as the wound has to heal from the inside out. Heels are particularly vulnerable to pressure sores and the sores can cause permanent difficulty with walking as the skin becomes tight and is vulnerable to breaking down.

If there is a failure to recognise and treat the most serious of pressure sores, the necrotic tissue can extend over a larger surface area, and can invade the bone. This in turn can lead to  amputation  of the affected area.

The healing process can take a significant period of time, and often requires ongoing treatment by district nurses or  tissue viability nurses , who specialise in treating ongoing sores.

The healing process is complicated by the cause of the sore, a lack of mobility, and so a carefully planned care regime which involves regular turning and repositioning, is crucial to aid recovery.

Can I bring a claim for medical negligence as a result of sustaining a pressure ulcer?

If you or a family member or friend has suffered with a bed sore as a result of a medical professional failing to prevent a pressure sore developing, it may be possible to bring a claim.

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