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The Permanente Medical Group

Causes

Pressure ulcers often appear after you’ve been lying or sitting in the same position. The contact of the skin against a bed or wheelchair cuts off blood supply to the area. Your risk is greater if your skin is thin, either due to aging or an injury.

When your skin is dragged across surfaces, including bed sheets and wheelchair seats, it creates friction (resistance to motion). Moist skin may make friction worse. Wet skin loses its elasticity and is more vulnerable to pressure ulcers.

Your skin might also weaken when your skin moves in the opposite direction of the surface you are sitting or lying on. For example, if the head of your bed is raised, you may slide down your sheets. This creates shear (two objects moving in opposite directions). While your tailbone slides down the raised bed, your skin may remain in the same place, which causes stress on the underlying muscle and tissues and can cause damage to these tissues and tiny blood vessels under your skin.

Risk Factors

You are at greater risk for developing pressure ulcers if you are:

• An older adult.
• Have poor nutrition.
• Severely overweight or severely underweight.
• Unable to control your bladder or bowel movements.
• A smoker.
• Sweaty or have skin that is too dry or too moist.
• In a wheelchair.
• Suffering from a chronic illness or are in poor health.
• Recovering from an injury, illness, or surgery in bed.
• In a coma or have poor mental clarity.

Your risk of developing pressure ulcers is also higher if you are not able to feel pain or discomfort, such as from a spinal cord injury or a neurological disorder.

Other risk factors include weight loss, muscle weakness, or a medical condition, such as diabetes. Smoking and having a condition that causes muscle spasms, such as cerebral palsy, also puts you at risk of pressure ulcers.

The areas of the body that are most at risk for pressure ulcers are where the skin covers bony areas, including your tailbone, buttocks, shoulder blades, hips, ankles, heels, and elbows.

Symptoms

Symptoms of pressure ulcers are categorized in the following ways:

• The skin is intact. In light-colored skin, you may notice a red spot. In dark-colored skin, you may notice a blue or purple spot. The skin might be tender, soft, and warmer than the skin around it.
• You develop a shallow open sore or fluid-filled blister on the skin.
• The wound becomes deeper and looks more like a crater. There may be some yellowish-colored or dead tissue in the wound. The tissue around the sore might also become affected.
• You have a large amount of tissue loss. You may see bone, muscle, and other tissue around the sore and dark, dead skin inside the wound. Healthy tissue and skin surrounding the wound is now also becoming damaged.
• Suspected Deep Tissue Injury or SDTI: The skin is dark red or purple but intact. It is not obvious by looking at the area how deep the injury may be but the concern is that it may be deeper than just the skin.
• Unstageable: The ulcer is black, brown, or yellow. It is unclear exactly how deep the ulcer is. These may need to be examined by a surgeon to assist with healing.
  

Screening and Diagnosis

Pressure ulcers are diagnosed by a physical examination. If we believe necessary, we may ask for a culture or a sample of a small piece of tissue to view it under a microscope to determine if the area is infected. Blood tests may be ordered to help us identify a possible infection and help determine whether you are getting proper nutrition to help your body heal.

Although rare, tissue damaged from severe pressure ulcers may become cancerous. We may order a biopsy to check for cancerous tissue in wounds that do not heal.

Treatment

The sooner you receive treatment for pressure ulcers, the easier they are to treat and heal. Let us know immediately (or your hospital nurses or other care team member when you are in the hospital) if you notice any tender or red areas on your skin.

Early treatment 

Early treatment includes relieving pressure from the areas of your skin where you have pressure ulcers. We will regularly reposition your body, and might use a special air mattress, cushion, or bed to assist in redistributing your weight . 

We regularly clean your wounds to prevent infection. We usually cover the pressure ulcers in a bandage or other dressing to keep the wound moist and the skin around the wound dry. In this case, moisture in the wound actually helps the wound heal much faster.

Medications 

After reviewing your medical history and doing a physical exam, we may need to prescribe medications. Depending on your condition these may include:

Pain medications to reduce pain associated with serious pressure ulcers, dressing changes, and during procedures to remove dead tissue. The types of pain medications we may use include ibuprofen (Advil, Motrin, or a similar generic medicine) and naproxen (Aleve or equivalent generic). We might also prescribe something that you apply directly to your skin.

Antibiotics to treat infected pressure ulcers. We will make an assessment regarding whether the wound is infected or not. If the wound is infected, you may need an antibiotic topically, by mouth, or by IV. We may also use an antimicrobial dressing for your wound care.

Muscle relaxants to reduce muscle spasms that can put pressure on your skin and make pressure ulcers worse. We may prescribe medication such as diazepam (Valium) or dantrolene (Dantrium).

Remove dead tissue 

The process of removing damaged or dead tissue is called “debridement.” When pressure ulcers damage the skin or tissue under the skin so that it will not heal, we must remove the dead skin and tissue. There are several ways we may perform debridement:

• Autolytic. Uses your body’s natural process of removing dead tissue with enzymes. We keep the wound moist and wrapped during the process.
• Mechanical. Use of special tools (such as a whirlpool bath) to remove the dead skin and tissue.
• Enzymatic. Applying chemical enzymes to your wound to remove the damaged tissue.
• Surgical. Cutting away the dead tissue and skin during a surgical procedure or at the bedside.

Surgery to repair severe pressure ulcers 

Very rarely, pressure ulcers get worse instead of better with treatment or they stay the same and “stall.” In these cases, we may have to remove the dead tissue, muscle, and skin and replace it with skin, tissue, or muscle from another area of your body (graft). The type of surgery depends on the location and severity of the pressure ulcers. Surgery allows your body to heal, treats infection, and can prevent further damage to the skin, muscles, and tissue.

It may take several weeks or months to successfully treat pressure ulcers. It will be important for you to remain diligent in your self-care during this time.

Prevention Methods

When you have an illness or injury that makes you bed-bound or wheelchair-bound you can reduce your risk of developing pressure ulcers by practicing prevention methods.

Prevention basics 

The best way to reduce your risk of getting pressure ulcers is to regularly change your position. If you are unable to move on your own, ask a caregiver or loved one to help move your body, (every 15 minutes if you are in a wheelchair or every 2 hours if you are in bed).

If you are in a wheelchair, there are special cushions to sit on that will prevent pressure ulcers.

If you are in bed, you may rest on a special mattress that reduces pressure on your skin. It is very important that you do not slide across your sheets or rub your skin when changing positions.

Other prevention methods include quitting tobacco use, eating a healthy diet, and getting regular physical activity. Certain kinds of activity may not be possible for you, depending on your illness or requirements of your recovery.

During a hospital stay we may recommend that you meet with one of our physical therapists to learn daily exercises to help prevent pressure ulcers or assess your wheelchair for cushion recommendations.

Get good nutrition 

Eating a healthy diet is important to maintain the health of your skin. You may need additional fluids, protein, and calories while you recover from pressure ulcers. Drink plenty of water to keep your skin healthy. We might also prescribe a daily dose of vitamins and minerals or a protein supplement.

Prevention While in a Hospital Bed

During a hospital stay we regularly evaluate your risk of getting pressure ulcers. Our nurses and team of care providers will work with you to help prevent pressure ulcers. We will encourage you to do the following:

Change positions. We may raise the head of your bed and elevate your legs so that you lie at an angle with pillows under your back, side, or knees for support. Whether in bed at home or in the hospital, change your position every 2 hours.

Provide correct support. Avoid lying directly on your hip to protect the bony areas underneath your skin. We might also place cushions under your calves and ankles to relieve pressure on your heels.

Use devices. You may need a special device, such as a trapeze bar, to lift your upper body and reposition yourself in bed. We might also place bed sheets underneath you to lift you into a new position to avoid creating friction against your skin.

Use a special mattress. We may use foam cushions or wedges or a special air mattress to reposition your body.

Prevention While in a Wheelchair

If you must remain in a wheelchair, it is important to follow these steps to prevent pressure ulcers from developing:

Frequently change positions. We recommend that you shift your weight every 15 minutes on your own. We can help you reposition your whole body every 60 minutes.

Use a special cushion. A special cushion filled with air or gel can help redistribute the pressure in the buttock area of your body.

Build strength. Wheelchair push-ups and other physical activities can help to build upper body strength.

Use a special wheelchair. These wheelchairs tilt your hips, back, and bottom to change the way you sit in the chair. By changing your position frequently, it redistributes the pressure on the skin.

Proper Skin Care

Regular care of your skin can both prevent and treat a pressure ulcer. Remember to:

Check your skin. Look for signs of pressure ulcers, such as a change in skin color, red spots, pimples, or sores. You may use a mirror to see all areas of your skin or ask for the help of a caregiver or loved one. We regularly do a thorough check of your skin while you are in the hospital.

Keep your skin dry. Use talcum powder on areas of skin that are sweaty or moist. If you have problems with bowel or bladder control (incontinence), regularly change urinary pads, and use a moisture barrier cream several times a day to help protect your skin.

Practice good hygiene. Clean your skin with a mild soap, and warm water every day and gently pat your skin dry. After you bathe, while your skin is still moist, is the best time to apply a moisturizer. Another option may be the use of a no-rinse cleanser.

Protect dry skin. Even though moisture is harmful to your skin when avoiding pressure ulcers, dry skin can also increase your risk. If you have dry or itchy skin, be sure to apply a lotion or cream twice a day. Lotions or creams that contain dimethicone will provide the best moisturization. And as stated above, it is best to apply these just after you bathe while your skin is still damp.

Your Care with Me

If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options and develop a treatment plan that is right for you.

If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours per day, 7 days per week.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

Coordinating Your Care

Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

Convenient Resources for You

As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.