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Pressure Ulcers and Wounds/Injury Management

Condition: Pressure ulcers, also called pressure injuries, pressure sores, or bedsores, are localized injuries to the skin and/or the underlying tissue. This can include injury to the skin, muscle and/or bone.

Background: Pressure ulcer formation is one of the most common complications of hospitalization. It most commonly develops over areas of bony prominences. It is due to a combination of pressure, shearing, and moisture leading to decreased blood and fluid flow to tissue. This eventually results in tissue becoming damaged and dying off, and thus a pressure injury forms. A pressure injury can develop as quickly as over two hours, or sometimes longer over days.

Risk Factors: There are multiple risk factors to developing a pressure ulcer. The most common risk factors includes poor nutrition, immobility, sensory deficits, incontinence, and vascular diseases. These risk factors are commonly seen in patients who are older, have spinal cord injuries, strokes, neuropathies and amputations. When an individual has difficulty moving and cannot change positions easily, such as with spinal cord injury or an older person who has limited movement, prolonged pressure develops over the tissue leading to damage. When an individual has difficulty sensing their skin, they may not realize when skin is in pain, being rubbed against objects like clothing, bedding, or that they are sitting in urine/feces. This leads to tissue damage and pressure ulcer formation. Patients with poor nutrition and vascular diseases are at high risk due to decreased blood flow and nutrition getting to their tissue.

History and Symptoms: Early signs of pressure ulcers included changes in skin color, swelling, and tissue texture changes. Many times the skin will appear reddened, and it will not turn white when pressed over the area. Over time tenderness, or even blister formation and possible pus drainage can develop.

Physical Exam: Physicians usually examine the location, appearance and size of the wound, as well as the surrounding tissue. They will stage the pressure ulcer and use this information to track changes with the ulcer over time.

Diagnostic Process: To help determine if a wound is a pressure ulcer, physicians often check if there is an odor or seeping from the wound, or dead tissue. Common areas where they occur are on the buttocks, elbows, heels and the back of the head.

Rehab Management: A physical medicine and rehabilitation (PM&R) physician, also known as a physiatrist, plays a key role in managing and coordinating the care for patients with pressure ulcers. The area is examined and determination made if tissue needs to be removed. PM&R physicians (physiatrists) work in collaboration with patients to create a directed plan for rehabilitation, taking into account the patient's underlying condition, medical problems, nutrition and daily activities. A PM&R physician helps to identify specific activities or positions the patient commonly uses that aggravate the problem. They provide prescriptions for wound care and dressings whereby decreasing chances of infection. A PM&R physician will determine and prescribe appropriate equipment to redistribute pressure around the area allowing for healing. A PM&R physician works with the patient to optimize their nutrition, as well as control their pain. PM&R physician ultimate goal is to assist the patient to be as independent as possible and return to their normal daily life.

Other Resources for Patients and Families: A guide, "Pressure Ulcers: What You Should Know: A Guide for People with Spinal Cord Injury” is available from the Consortium for Spinal Cord Medicine.

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