Growing up, I never thought that I would become an expert on pressure sores, their treatment, and management. One year after my injury though, I ended up with an ischial pressure sore on my left buttocks. Eight months in bed, and a failed flap surgery, taught me that I must become my own advocate in preventing, treating, and eliminating pressure sores.
Prevention of Pressure Sores:
Sitting on a cushion that works for you, is the first step in avoiding pressure sores.
I’m quadriplegic, and unfortunately I sit with more pressure on my left buttocks. This is due to heterotopic ossification on my right hip. To combat this pressure problem on my left side, I sit on a High Profile Quadtro Select ROHO cushion. The four-inch air cells allow me better pressure management than a gel filled cushion. Also, with the Quadtro cushion, you have the ability to manage the amount of air pressure in four quadrants of the cushion. For my seating position, I lower the amount of air in the back right quadrant. This compensates for the heterotopic ossification, and gives me a little less pressure on my left side.
Another key factor in preventing pressure sores is by doing periodic pressure releases and position changes. Everyone is different, and so is their skin. I am constantly changing my seating position by moving my hips back and forward on the cushion. I know initially it was recommended to me that I relieve pressure off my buttocks for at least a minute, every 15 min. that I’m sitting up.
Limited Sitting Times.
I’ve been injured for 17 years. I used to be able to sit up for 16 hours at a time, but that’s probably too much. I now get off my buttocks midday for at least a couple of hours.
What happens if you get a pressure sore even though you’ve followed the steps to prevent one?
The major key in preventing pressure sores from getting worse, is immediately getting off of them as soon as you have any indication that your skin is breaking down. Skin breakdown can happen fast! There really is no other cure or treatment. You have to relieve the pressure! When the damage has been done, you’ll have to assess the stage of the pressure sore.
Treatment of Pressure Sores:
I’m not going to go into the four stages of pressure sores. I’ll leave that to the experts at the National Pressure Ulcer Advisory Panel.
Here’s their definition of a pressure sore, and the six stages of pressure sores. Note that there were originally four stages, and they have recently added two more stages, which cover deep tissue injury and unstageable pressure sores.
Pressure Ulcer Definition
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.
Pressure Ulcer Stages
Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk)
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
It’s worth repeating a second time. The major thing you can do to help heal pressure sores is to get off of them. I cannot stress this enough. Ischial pressure sores Will Not heal while you are sitting up. You must relieve the pressure. I’m currently treating an ischial pressure sore. In fact, I’m writing this post using my laptop and Dragon Naturally Speaking software, while laying flat on my back in bed. My current Regiment is three hours up in the morning, on bowel program days, and one to three hours up in the evening. The rest of the time is spent in bed. On the non-bowel program days, I sit up for one hour in the morning, and one to three hours in the evening. This sucks! But it’s crucial for healing, and I know it.
Wound Care Dressings:
The second major key of treating pressure sores is how you dress the wound. Moist environments are necessary for pressure sores to heal. Initially, I used to use duoderm and tagederm dressings to treat pressure sores on my buttocks. For me personally, I found that the sticky adhesive on the dressings caused allergic reactions to my skin. Finally, after trial and error I found that Allevyn non-adhesive pads worked best for me. I was also allergic to certain types of paper tapes, and finally found a 3M tape that my skin was not allergic to. Here are a list of dressings from EPERC that are commonly used to treat pressure sores.
Dressings Living tissue requires moisture for transport of oxygen and nutrients. A moist ulcer environment promotes the migration of fibroblasts and epithelial cells; growth factors are present in the serous exudate that speed healing. In contrast, a dry environment is conducive to necrosis and eschar.
There are 6 classes of dressings distinguished by the wear time and whether you want to add or remove fluid in order to maintain the ideal moist, interactive ulcer-healing environment. A dry ulcer needs to have moisture added through a hypotonic gel (donates water). With wet exudates, a hypertonic gel or foam is used to remove water.
- Polyurethane foams (LYOfoam, Allevyn, Nu-Derm, Flexzan): most absorptive; used under a covering secondary dressing.
- Alginates (Kaltostat, Sorbsan): dessicate an overly wet wound, prevent maceration of surrounding skin from excess fluid, and are hemostatic and may reduce infection risk.
- Hydrogels (IntraSite, Elasto-Gel, ClearSite, Aquasorb): used for wounds with larger volumes of exudate. Require a secondary dressing to secure.
- Hydrocolloid wafers (DuoDerm, Comfeel, Tegasorb, Restore): promote autolysis, angiogenesis and granulation. Self-adhesive. Remain in place for 5-7 days. Often used to “seal” a wound that is otherwise clean in order to promote healing. Can also be used to seal an underlying dressing in order to maintain a moist environment in which the wound can heal. Note: do not to use an occlusive dressing if there is a substantial risk of infection.
- Thin films (OpSite, Tegaderm): for skin at risk or Stage I pressure ulcers. Can also hold another type of absorbent dressing in place.
- Cotton Gauze: used to cover the primary dressing. Rarely an appropriate dressing for a significant skin ulcer. Note: Saline wet-to-dry dressings are only useful for mechanical debridement.
Getting a doctor’s recommendation on which dressing to use is usually best. You want a dressing that will soak up excess moisture for certain wounds, and enhance moisture for other types of wounds. I have found that wounds that get dry are the hardest to heal. They tend to want to scab up. Ischial pressure sores will not heal correctly if they scab up in a dry environment. If that happens, I take one of the Alleyven foam dressing pads, and wet it down slightly. I place this against the wound, which keeps the pressure sore slightly moist. I secure it against my skin with a piece of gauze over the foam dressing, or some other type of dressing that will cover the moist dressing in a wet to dry fashion.
Drinking plenty of liquids and eating a nutritional high-protein diet is a necessity for helping to heal pressure sores. Medical recommendations suggest eating .5 to .8 g of protein per pound of body weight per day. That’s 60 to 100 g of protein for a 125 pound person. I weigh 210 pounds, and try to eat 100 g of protein a day at a minimum. This is not easy to do. Some high-protein foods that are also nutritional include chicken breasts, cottage cheese, fish, and legumes.
Sometimes pressure sores just happen. You do your best to prevent them, but fighting the effects of gravity isn’t easy. Working at preventing them initially is obviously best, but if you do get one, and especially an ischial pressure sore, get off of it immediately. Consult your doctor, and start increasing the protein you eat in your diet.