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Pressure ulcer, also popularly known as eschar, is a wound that appears due to prolonged pressure and consequent decrease in blood circulation in a certain part of the skin.
This type of wound is more common in places where the bones are in greater contact with the skin, such as in the lower back, neck, hips or heels, because there the pressure on the skin is greater, worsening circulation. In addition, pressure ulcers are also more common in bedridden people, as they can spend several hours in a row in the same position, which also makes circulation difficult in some areas of the skin.
Although they are skin wounds, pressure ulcers take a long time to heal and this happens for several reasons, such as weakness in the person's general condition, alteration of deep layers of the skin and difficulty in completely relieving all the pressure of the affected locations.Therefore, it is very important that all types of ulcers are evaluated by a doctor or nurse, so that treatment with the most appropriate product can be started, as well as the most important precautions to accelerate healing.
Main stages of pressure ulcer
Initially, the pressure ulcer appears on the skin only as a red spot, but over time this site may present a small wound that does not heal and that increases in size. Depending on the time of ulcer evolution, it is possible to identify 4 stages:
The first stage of pressure ulcers is known as "blanchable erythema" and means that, at first, the ulcer appears as a reddish patch that changes color to white or paler when pressed, and that maintains that color for a few seconds or minutes, even after the pressure has been released.In the case of black or darker skin, this stain may also have a dark or purplish coloration, instead of red.
This type of stain, in addition to being white for a long time after being pressed, can also be tougher than the rest of the skin, be hot or colder than the rest of the body. The person may also refer to a tingling or burning sensation in that place.
What to do: at this stage, pressure ulcers can still be prevented, so the ideal is to keep the skin intact and improve blood circulation. For this, you should try to keep the skin as dry as possible, apply a moisturizing cream frequently, as well as avoid positions that can put pressure on the area for more than 40 minutes in a row. In addition, it is important to have regular massages on site to facilitate circulation.
At this stage, the first wound appears, which may be small, but appears as an opening in the skin in the region of the blanchable erythema spot.In addition to the wound, the skin in the area of the stain appears thinner and may look dry or may be brighter than normal.
What to do: although the wound has already appeared, at this stage it is easier to stimulate healing and prevent an infection. For this, it is important to go to the hospital, or a he alth center, so that the place can be evaluated by a doctor or nurse, in order to start treatment with the most appropriate products and dressings. In addition, the pressure of the site should continue to be relieved, as well as drinking plenty of water and increasing the intake of foods rich in protein and vitamins, such as eggs or fish, as they facilitate healing.
In stage 3, the ulcer continues to develop and increase in size, starting to affect deeper layers of the skin, including the subcutaneous layer, where fat deposits are found.That is why, at this stage, inside the wound it is possible to observe a type of irregular and yellowish tissue, which is formed by fat cells.
At this stage, the depth of the ulcer varies according to the affected site and, therefore, it is normal that the subcutaneous layer cannot be seen in the nose, ears or ankles, as it is not present.
What to do: adequate treatment should be maintained under the guidance of a nurse or doctor, and a closed dressing must be applied every day. It is important to drink a lot of water during the day and bet on a diet richer in protein. In addition, the pressure of the affected areas should also continue to be relieved, and the doctor may even recommend the purchase of a mattress that varies the pressure along the body, especially in people who are bedridden for a long time.
This is the last stage of pressure ulcer development and is characterized by the destruction of the deeper layers, where muscles, tendons and even bones are found.In this type of ulcer, there is a high risk of infection and, therefore, the person may need to be hospitalized to have more regular dressings and receive antibiotics directly into the vein.
Another very common feature is the presence of a very foul smell, due to the death of tissues and the production of secretions that can become infected.
What to do: These ulcers must be treated in the hospital and you may even need to stay in the hospital for antibiotics to prevent possible infection. It may also be necessary to remove layers of dead tissue, and surgery may be recommended.
Main nursing care
One of the most important nursing care in the case of pressure ulcers is the implementation of an adequate dressing, however, the nurse must also maintain a regular assessment of the wound, as well as teach the person to avoid ulcer worsening and assess the risk of new ulcers.
1. How to make an ulcer dressing
The dressing must always be adapted to the type of tissue present in the wound, as well as other characteristics that include: release of secretions, smell or presence of infection, in order to promote adequate healing.
So the dressing can include different types of material, the most common of which include:
- Calcium alginate: these are foams widely used in pressure ulcers to absorb the released secretions and form an ideal environment for healing. They can also be used if there is bleeding, as they help stop the bleeding. They usually need to be changed every 24 or 48 hours.
- Silver alginate: in addition to absorbing secretions and promoting healing, they also help treat infections, being a good option for infected pressure ulcers;
- Hydrocolloid: ideal for preventing the appearance of a wound during stage 1 pressure ulcers, but can also be used on more superficial stage 2 ulcers;
- Hydrogel: can be used as a dressing or gel and helps to remove dead tissue from the wound. This type of material works best on ulcers with little secretion;
- Collagenase: is a type of enzyme that can be applied to the wound to degrade dead tissue and facilitate secretion, being widely used when there are large areas of dead tissue to remove.
In addition to using the appropriate dressing, the nurse must remove the remains of the previous dressing and properly clean the wound where, in addition to using saline, a scalpel can be used to remove pieces of dead tissue, the which is called debridement. This debridement can also be done directly with the compress during cleaning or done with the application of enzymatic ointments, such as collagenase.
Check out more about ointments for treating pressure ulcers.
Most common sites for pressure ulcers
2. How to assess pressure ulcer
During the treatment of the wound, the nurse must pay attention to all the characteristics that he can observe or identify, so that an evaluation can be made over time, in order to understand if adequate healing is taking place. This evaluation is also very important to consider changing the dressing materials, so that they remain adequate throughout the treatment.
Some of the most important characteristics that should be evaluated during all dressings include: size, depth, shape of edges, production of secretions, presence of blood, smell and presence of signs of infection, such as redness of the skin in back, swelling, heat or pus production. Sometimes, the nurse can even take pictures of the wound site or make a drawing with paper under the wound, to compare the size over time.
When evaluating the characteristics of the pressure ulcer, it is still recommended to pay attention to the skin around the wound, since if it is not properly hydrated, it can contribute to the increase of the ulcer.
3. What to teach the person with pressure ulcer
There are several teachings that are very important for the person with a pressure ulcer and that can help to greatly improve the speed of healing, as well as avoid complications. Some of these teachings include:
- Explain to the person the importance of not staying more than 2 hours in the same position;
- Teach the person to position so as not to apply pressure to the ulcer;
- Show how to use pillows to relieve pressure on boney places;
- Teaching about the harmful effects of smoking on blood circulation and encouraging people to stop smoking;
- Explain about signs of possible complications, especially infection.
Furthermore, it may also be important to refer the person for a consultation with a nutritionist, since adequate nutrition is very important to promote collagen formation and wound closure.
If you are a bedridden person, here's how to position the person in bed:
4. How to assess the risk of new ulcers
People who develop a pressure ulcer have an increased risk of developing new ulcers. For this reason, it is advisable to assess the risk of having a new ulcer, which can be done using the Braden scale.
The Braden scale assesses 6 factors that can contribute to the appearance of an ulcer and include: the person's ability to feel pain, skin moisture, physical activity level, mobility capacity, nutritional status and the possibility of skin friction.A value ranging from 1 to 4 is assigned to each of these factors, and at the end all values must be added together to obtain the risk rating of developing a pressure ulcer:
- Less than 17: no risk;
- 15 to 16: light scratch;
- 12 to 14: moderate risk;
- Less than 11: high risk.
According to the risk, as well as the factors with the lowest score, it is possible to create a care plan that helps to prevent a new ulcer, in addition to facilitating the healing of the existing one. Some care can include properly hydrating the skin, encouraging a more adequate diet or encouraging physical activity, even moderate.