Running head: PRESSURE ULCERS 1

Pressure Ulcers

Ariel Combs

Gregg Pennington

Anatomy and Physiology 1 Theory

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Introduction (Description and Body Systems Involved)

More commonly known as “bedsores”, which are injuries to skin and underlying tissue

resulting from prolonged pressure on the skin. Pressure Ulcers often develop on skin that covers

bony areas of the body, like the heels, ankles, hips and tailbone. Those most at risk of bedsores

are those with a medical condition that limits their ability to change positions or those who

spend most of their time in a bed or chair. (Mayo Clinic, 2017). From the years 2008-2012, the

organization Ostomy Wound Management (Bauer, 2016) conducted a study that concluded the

5-year average number of admitted patients with 1 or more pressure ulcers in the US from 2008

to 2012 was determined to be 670,767. Looking more in depth at the injury, it can be concluded

that the ulcers form due to a lack of nutrients needed to survive. The cells in skin tissue begin to

die when the underlying blood vessel has so much pressure applied, that it cannot reach the

cells. When the cell is deprived of its essential nutrients, mainly oxygen, it shifts to anaerobic

respiration. That process increases the amount of lactic acid within the cell, initiating the release

of lysosomes. These lysosomes further break down the cells and the cell membrane loses its

control over the normal functioning of the cells. Due to this, the mitochondria gets completely

damaged making what is remaining of the cell inactive, and the leftover proteins are denatured.

The nucleus inside this cell changes and the DNA, as well as other structures located inside the

nucleus, and becomes damaged. At the end, cytoplasm gets overrun by external fluids making

the cell walls swell. Ultimately, the cell membrane bursts leading to the death of the cell. The

enzymes and the other substances produced during the process of cell death can further kill

other healthy cells thereby spreading the necrosis condition. (Mayo Clinic, 2017).

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Pressure ulcers, depending on which stage, can affect many systems of the body. Pressure

ulcers occur when pressure cuts off circulation to certain areas of tissue or skin, resulting in a

lack of nutrients needed to live, causing the tissues to die. In more severe cases, when the ulcers

grow and increase their depth, they can damage tendons, muscles, and even bones. In stage 1, the

only body system affected would be the integumentary system, for only the deeper skin tissues,

near the supplying blood vessels, have been damaged. In stage 2, it is, again, only the

integumentary system that is affected, but now with the epidermis and dermis splitting open.

Similarly, stage 3 affects the integumentary system, but travels further under the skin, into fat, or

tissues that cover bone and muscle. Lastly, stage 4 affects the integumentary system, along with

the muscular and skeletal systems. This is due to the fact that the ulcer travels even further into

the body, breaching tissues and exposing and damaging bones and muscles. (MSKTC, 2007).

Normal Anatomy of the Body System Effected

The integumentary system, the body system most largely affected by pressure ulcers, has

several parts that make up its anatomy. Consisting mostly of skin, divided into two distinct

layers: The epidermis and the dermis. The Epidermis is the thinner more superficial layer of the

skin. The epidermis is made up of 4 cell types: Keratinocytes, which produce keratin protein that

helps protect the epidermis. Melanocytes that produce the brown pigment melanin. Langerhan

cells, that participate in immune response. And merkel cells, which participate in the sense of

touch. (Rapid Learning, 2016). The epidermis contains 3 cell types: Adipocytes, macrophages

and fibroblasts. The dermis is the deeper, thicker layer composed of connective tissue, blood

vessels, nerves, glands and hair follicles. There are two main divisions of the dermal layer: The

papillary region; which is the superficial layer of the dermis, made up of loose areolar connective

tissue with elastic fibers. The dermal papillae, on the other hand, is the fingerlike structures that

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invade the epidermis, and contain capillaries which respond to touch. There is also a reticular

region of the dermis that is made up of dense irregular connective & adipose tissue, contains

sweat lands, sebaceous (oil) glands, & blood vessels. (Rapid Learning, 2016). The integumentary

system is also composed of hair and nails, but those aspects are very rarely, if at all, affected by

pressure ulcers.

Normal Physiology of the Body System Effected

The integumentary system provides several functions that keeps the body in balance and

in condition for survival. Firstly, there is thermoregulation, which keeps the body’s temperature

in the spectrum of 97-99 degrees Fahrenheit. Thermoregulation cools the body down through the

evaporation of sweat and dilation of blood vessels, but generates heat, mostly, by muscles

shivering and the constriction of blood vessels. The integumentary system also provides

protection for the body, for the skin acts as a physical barrier. This system even includes

cutaneous sensation, which are sensations like touch, pressure, vibration, pain, warmth or

coolness. Additionally, the skin is involved in the absorption of water-soluble molecules and the

excretion of water and sweat. Wound healing is another aspect of the integumentary system. For

instance, when a minor abrasion occurs basal cells of the epidermis break away from the

basement membrane and migrate across the wound. They migrate as a sheet, when the sides

meet the growth stops and this is called contact inhibition. (Rapid Learning, 2016). In deep

wound healing, a clot forms in the wound, blood flow increases and many cells move to the

wound. The clot becomes a scab; granulation tissue fills the wound and intense growth of

epithelial cells beneath the scab. The scab falls off and the skin returns to normal thickness.

(Rapid Learning, 2016).

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Mechanism of the Pathophysiology

There are two mechanisms that contribute to pressure ulcer development: External

pressure that compresses blood vessels, or friction and shearing forces that tear and injure blood

vessels. External pressure applied over a bony area of the body can result in obstruction of the

blood capillaries, which deprives tissues of oxygen and nutrients. This can cause a deficiency of

blood in a particular area, an inadequate amount of oxygen available to the cells, inflammation,

and necrosis, leading to ulcer formation. (Li, 2011). Ulcers due to external pressure usually occur

over the tailbone and the heels. Friction is damaging to the superficial blood vessels directly

under the skin. It occurs when two surfaces rub against each other. For instance, the back can be

injured when patients are pulled or slid over bed sheets while being moved up in bed or

transferred onto a stretcher. A shear is a separation of the skin from underlying tissues. (Li,

2011). When a patient is partially sitting up in bed, their skin may stick to the sheet, making them

susceptible to shearing where the underlying tissues move downward with the body toward the

foot of the bed. In all these cases, the skin is damaged and is prevented from performing its

designed purpose. As a result from the forming ulcer, the skin and other tissues in the area will

begin to die, not allowing the skin to act as a physical barrier for the body. The dead skin will

wither and start to harvest bacteria, doing the exact opposite of the skin’s intent, putting the body

at great risk for infection, or in severe cases, exposing bone or muscle it was meant to shield.

Prevention

Pressure ulcers can be prevented in a number of ways, whether in a bed or a wheelchair.

The most important piece of advice for preventing pressures ulcer, regardless of where situated,

would be to redistribute weight, or to relieve pressure on the skin. If in a bed, change positions

every two hours, but if in a wheelchair, make it every fifteen minutes. Also, try to avoid sliding,

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slipping, slumping, or being in positions that put pressure directly on an existing pressure sore. Try to

keep the head of a bed, a recliner chair, or a reclining wheelchair raised no more than 30 degrees.

Another important aspect of prevention is to take care of the skin itself. Bathe as often as need be to

be clean, using warm water, being careful not to scrub too roughly. After bathing, use moisturizing

creams and lotions to keep skin from getting dry, for dry skin is damaged more easily. Be sure to

check over skin daily for signs of pressure ulcers, paying attention to the bony areas, like the hips,

knees, elbows, and heels. Also, if overweight, check in areas like skin folds or other areas that may

rub together. Plus, when in the beds or wheelchair, be sure to talk with a doctor to ensure there is an

appropriate amount of padding provided between the body and the surface. (WebMD, 2015). Studies

also show that nutrition plays a role in preventing pressure ulcers. A pattern was frequent among

those bedridden that if there was a higher intake of vitamin c, there was a lower risk of developing

pressure ulcers. (Bauer, 2016).

Treatment

When treating a pressure ulcer, the most important thing to remember is to keep the

wound covered and slightly moist. The doctor will inform and demonstrate how to change and

clean the wound properly. Most of the time, saline solution will be used to clean the wound

between bandage changes. When applying a new bandage, make one slightly moist and apply it

directly over the ulcer, or into the area if it has progressed further. Take another bandage, but be

sure to keep it dry, and apply it over the other bandage to keep area clean and dry. The doctor

might want to also remove the dead skin, since dead tissue serves as a good place for infection to

start. If this treatment option is not making any progress, the doctor may have other options to

choose from. To promote the healing process, the doctor may offer skin grafts, electrical

stimulation, hyperbaric oxygen therapy, protein supplements, and ultrasound (soundwave)

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therapy. (WebMD, 2015). Along the road to recovery, the doctor can prescribe medications that

can aid in pain management, if any, as pain can be present for some individuals, but not all.

Clinical Relevance (Nursing Care Plan)

In the medical world, many in the field make use of something called a nursing care plan,

to ensure that the patient is properly cared for. The first step in this process would be to collect

and analyze the information on the issue. In this case, the patient would show signs of a

compromised skin integrity; which would be determined by inspecting and observing any

changes in the skins condition. For instance, if the skin shows signs of redness, swelling,

drainage, or excessively warmer than the rest of the body. (Mayo Clinic, 2017). After

determining the patient is at risk for, or has, a pressure ulcer, the nest step in the plan would be to

create goals. These can be short term or long term. In the case of bedsores, a short term goal

could be preventing further tissue damage and possible infection, and a long term goal could be

full tissue repair and regeneration in the site. The next step would be taking actions to carry out

the goals established. So, to prevent further damage or infection, the wound site would need to

be kept clean and dry. The wound would also need to be dressed and changed daily, and the

patient would need to be positioned to alleviate pressure from the site. As for the long term goal,

achieving this could be possible, or not, depending on the severity and what stage was reached. If

caught soon enough and the wound is more superficial, the easier it will be to follow the care

plan and achieve the desired results. As it reaches more internal structures, the longer it will take

to heal, if at all for there may be a large presence of necrotic tissue that have lost the ability to

regenerate. The final step of the nursing care plan would be to make an evaluation. This would

state whether the short and long term goals were met, and a discussion with the patient. The

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discussion usually regards prevention of developing another sore, and improving overall health.

(Mayo Clinic, 2017).

Conclusion

In the end, pressure ulcers are injuries to skin and underlying tissue resulting from

prolonged pressure on the skin. The presence of these ulcers can keep the integumentary system

from protecting the body as it is intended to do, acting as a physical barrier, due to the fact that

the ulcer is an opened sore consisting of dead skin tissues, opening up and exposing more

internal layer of the body and risking infections. These ulcers are formed a couple ways: either

external pressure or friction and shearing. External pressure being anything that is an outside

force restricting the blood flow to an area, causing cell death. On the other hand, friction and

shearing are when there is a consistent reapplied pressure or rubbing, causing the more

superficial blood vessels to be damaged. Ultimately this can all be prevented by readjusting the

distribution of weight periodically, proper hygiene, and finding the right kind of support. If all

that fails, and a pressure ulcer forms, it is best to meet with a professional and go over treatment

options. In most cases, the simple clean, pack, and bandage routine will be picked up, but there

are other alternative options if there is no success; though many studies do back up the clean,

pack, and bandage routine as the preferred method of treatment.

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Citations

Bauer, Karen. (2016). Ostomy Wound Management. Volume number 62. Retrieved from

http://www.o-wm.com/article/pressure-ulcers-united-states-inpatient-population-2008-2012-

results-retrospective.

Li, Yue; Yin, Jun; Cai, Xueya; Temkin-Greener, Jna; Mukamel, Dana B. (2011). Association of

Race and Sites of Care with Pressure Ulcers in High-Risk Nursing Home

Residents. JAMA. 306 (2): 179–86. doi:10.1001/jama.2011.942.

Mayo Clinic. (2017). Bedsores (Pressure Ulcers). Retrieved from

https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-causes/syc-20355893.

MSKTC. (2007). Skin Care & Pressure Sores- Recognizing and Treating Pressure Sores.

Retrieved from http://www.msktc.org/sci/factsheets/skincare/Recognizing-and-Treating-

Pressure-Sores.

Rapid Learning. (2016). The Integumentary System. Retrieved from

http://www.rapidlearningcenter.com/biology/anatomy-physiology/05-The-Integumentary-

System.html.

WebMD. (2015). Pressure Sores: Prevention and Treatment. Retrieved from

https://www.webmd.com/skin-problems-and-treatments/tc/pressure-sores-prevention-and-

treatment-topic-overview#1.

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