Prevention and Rehabilitation
of Pressure Ulcers
Michael Kosiak , MD
MAY,1991. Decubitus. VOL. NO.2
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 Every care provider is well aware of the
complications manifested by the occurrence
of ulceration in the chair- or bed-ridden
patient.
 The healthcare professional is being required,
with increasing frequency to maintain and
rehabilitate the elderly and severely disabled.
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DEFINITION
 Pressure ulcers are localized areas of cellular
necrosis which usually occur over bony
prominences which are subjected for
prolonged periods of time to pressures in
excess of capillary pressure.
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INCIDENCE
 The incidence of ulcerations is considerably
greater in the spinal cord-injured hospital
population and many deaths in this group of
patients can be attributed to complications
arising from the presence of pressure ulcers.
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DISTRIBUTION
 While pressure ulcers can develop
over any area of the body subjected
to supra-capillary pressure for a
sufficient period of time.
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PRIMARY FACTORS
 Pressure
Working with normal and paraplegic rats, we
reported that microscopic examination of rat
muscle 24 hours after being subjected to
pressure of 70 mm Hg for two hours showed
a decrease or loss of cross-striations and
myofibrils, hyalinization of fibers and
neutrophilic infiltrations.
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PRIMARY FACTORS
 Pressure
When complete relief of pressure was
provided at regular five-minute intervals, as
with an alternating pressure support system,
the tissue showed consistently less change
or no change at all when compared with
tissues subjected to an equivalent amount of
constant pressure.
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PRIMARY FACTORS
 Pressure
This was true even at pressures as high as
240 mm Hg for three hours (Kosiak, 1959).
Pressure as high as 190 mm Hg when applied
either constantly or intermittently for up to
one hour showed no microscopic changes.
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PRIMARY FACTORS
 Friction and Shearing
Dmsdale (1973), working with swine,
demonstrated significant skin breakdown
when the tissue was subjected to both
pressure and friction, at a pressure
significantly less than that when necrosis
was caused by pressure alone (45 mm Hg
versus 290 mm Hg).
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PRIMARY FACTORS
 Temperature
Raising tissue temperature increases cellular
metabolism and, therefore, increases the risk of
ischemic necrosis.
 Aging
After the third decade, a progressive decrease in skin
pliability and elasticity has been reported .
whereas after the fifth decade, a rapid decrease in
blood flow through the skin occurs.
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CONTRIBUTING FACTORS
 Nutrition
Increased emphasis has recently been placed
on the role of nutrition during the acute and
convalescent phases of illness, especially on
the negative nitrogen and calcium balances
that inevitably appear after an acute insult.
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CONTRIBUTING FACTORS
 Nutrition
Protein insufficiency inhibits or prevents the
healing of ulcers.
For a good metabolic response, the patient
with a pressure ulcer should be eating 80100 gm of protein each day.
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CONTRIBUTING FACTORS
 Edema
 Anemia
 Endocrine Disorders
Diabetes mellitus is the most frequent
hormonal problem.
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PREVENTION
 Pressure ulcers are entirely
preventable.
 They need not and should not occur.
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GENERAL PREVENTIVE
MEASURES
 Education
 Identification of the high-risk patient
Those persons with impaired mobility, especially in
combination with decreased sensation or alteration in
the level of mental awareness, are obvious
candidates for skin breakdown if they are neglected.
A single episode of neglect of a comatose or
anesthetized patient for even an hour may result in
pressure necrosis.
Special consideration must be given to patients who
require sedation or mood-altering drugs.
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GENERAL PREVENTIVE
MEASURES
 Recognition of Impending Skin
Breakdown
 Specific Preventive Measures for
Elimination or Reduction of
Pressure
Position changes must be made around the
clock but not less frequently than every two
hours.
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MANAGEMENT
 General Measures
maintenance of the patient in a good
state of nutrition and hygiene should
be of high priority both to sustain
healing and to avoid infection.
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SPECIFIC MEASURES
 Pressure Relief
The ulcerated area should never be
subjected to any pressure unless absolutely
necessary for resting support.
Elimination of Shearing or Friction.
Reduction of Heat and Moisture Buildup.
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SPECIFIC MEASURES
 Debridement
Mechanical Debridement
Chemical Debridement
 Control of Infections
If infection is prevented or controlled,
healing begins to occur promptly and
rapidly.
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SUMMARY
The importance of providing pressure
relief to the areas supporting the
weight of the body must continue to
be stressed and materials and
methods must never be substituted
for sound nursing care.
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