Infection Control Practice in Management of Pressure Ulcer

1         Introduction

Being as medical writer and pharmacist working so long on such a topics the author comes up with many difficulties people faced on being on hospital bed and under treatment but scientific world has done remarkable job and now we are able to cure all of the pathologies almost very few left uncured We are living in the age of science and technology. As a result of this factor of developing science, there has been a cure for many of the diseases. This report is solely based upon the investigation of pressure ulcers to get a better understanding of controlling it. Another aspect that plays a major role is the incorporation of the disease to management such that it could get controlled effectively. Pressure ulcers, also called decubitus ulcers, bedsores, or pressure sores, range in severity from reddening of the skin to severe, deep craters with exposed muscle or bone (Roberts JL, 2000). Pressure ulcers significantly threaten the well-being of patients with limited mobility. Although 70 percent of ulcers occur in persons older than 65 years, younger patients with neurologic impairment or severe illness are also susceptible. (Kramer AM, 2002)

1.1        History

Pressure ulcers have been recognized as a disease since centuries. These ulcers have been found in Egyptian mummies, some of which are more than 5,000 years old. It is reported that Egyptians used honey for the treatment of pressure ulcers and wounds.

In the past, Persian people used a variety of topical applicants on wounds. Arabic people recommended nutritional support to cure the ulcer. A wide variety of remedies like honey, moldy bread, meat, plant extracts, CuSO4, ZnO, and alum have been used in the past. (Eltorai, 2003)

Hippocrates (460-370 B.C) had described pressure ulcer in association with paraplegia with bladder and bowel dysfunction.5 During the Renaissance, Ambrose Paré, a 16th-century French army barber-surgeon and founding the father of medical surgical practice, wrote in his autobiography about a wounded French aristocrat developing a pressure ulcer. He mentioned its cure with good nutrition, pain relief, and debridement; which is same as the present modality to some extent. (Adams, 1939)

In the 19th century, the discovery of bacteria by Pasteur, antisepsis by Lister and X-ray by Roentgen changed the understanding of these pressure ulcers in general. The 20th century brought in antibiotics which changed the scenario further. The later part of 20th century witnessed studies on key elements, biomechanics and new methods of management of these ulcers. (Levine, 1992)

2         Pressure Ulcer Classification

The specialist or medical caretaker can tell how terrible the issue is by taking a gander at the skin and measuring the sore. Every pressure ulcer is evaluated (this is called staging) in view of the measure of breakdown to the skin.(EPUAP, 2009)

  • Stage I: Non-branch able redness of in place skin

In place of skin with no-branch able erythema of a limited zone generally over a hard noticeable quality. Staining of the skin, warmth, edema, hardness or torment might likewise be shown. The hazily pigmented skin might not have noticeable whitening.

  • Stage II: Partial thickness skin misfortune or ankle

Incomplete and thickness loss of dermis displaying as a shallow open ulcer with a red-pink injury bed around without quagmire to be observed. May likewise display as an in place or open/cracked serum-filled or so dangerous filled rankle.

  • Stage III: Full thickness skin misfortune (fat obvious)

Full thickness tissue arises. Subcutaneous fat may be obvious yet bone, tendon or muscles are not uncovered. Some blog may be beginning it’s intact which may incorporate through undermining and burrowing.

  • Stage IV: Full thickness tissue misfortune (muscle/bone obvious)

Full thickness tissue with uncovered bone, tendon or muscle is seen at this stage. Quagmire or eschar may be an exhibit. Frequently incorporate undermining and burrowing.

  • Unstageable/Unclassified:

The top layer of the core is secured to dead tissue, which may have a yellow, tan, dim, green, or cocoa shading. It might likewise resemble a scab. The dead tissue covers a more profound, more genuine injury and needs to be uprooted by a specialist.

2.1        Causes

Pressure ulcers are caused by unrelieved pressure, applied with great force over a long interval (or with small force over a long interval)  many times and on the same place that disrupts the supply of blood to the capillary network, this block blood flow and deprive tissues of oxygen and nutrients. This external pressure or applied force (maybe because of postural abnormalities) must be greater than arterial capillary pressure to lead to inflow impairment and resultant local ischemia and tissue damage, this is major cause reported so far and in many places’s so it’s needed to be correct and it can be done easily by patient himself . A pressure sore is an ulceration caused by excessive pressure being applied to any tissue over an excessive duration. These ulcers are also called decubitus ulcers, bed sores or pressure ulcers, these names implying that they are caused by the main factor that causes this type of ulceration regardless of what posture or position the person is in when a sore is acquired. (Chow AW, 2002).

2.2        Contribution of Related Factors

There are few factors which of course are not the direct cause of ulceration but indirectly have a major or somewhere minor effect on causing or enhancing ulcers some are, (Antle D, 2001).

  • Skin temperature:

Increasing temperature by 1 degree has the effect of increasing metabolic demands of the cells and oxygen consumption by 10% in the area of the ulcer.Decreasing the temperature reduce the demand of cells but also causes a vasoconstriction that can decrease the blood supply to the area. If substantial necrosis of the tissue has occurred, the temperature of the area is reduced due to lack of arterial blood flow to the region.

  • Clothing and Climate:

Clothing and climate are two factors which contribute a lot in spreading and worst ulcers as they increase of decrease temperature of the body, cause irritation and burning sensation, and make lesions worst and prominent.

  • Age:

Increased stiffness and lower mechanical strength for the skin, interstitial fluid is resisted less by tissues causing cells to rupture when subject to pressure.

  • Body type:

People with less fat and muscles have higher pressure at their body prominences.

  • Collagen Formation:

Factors such as spinal cord injury or old age tend to favor the production of water soluble form of collagen at body temperature. This form is unstable decreasing the strength of tissues.

  • Nutrition:

Malnutrition reduces fat and muscles tissues, causing higher pressure on body prominences.

  • Fibrinolytic activity:

When fibrinolytic activity is reduced by a factor such as ischemia or friction, fibrin accumulates in the region possibly occluding blood flow.

2.3         Body Characteristics and Resulting Effects:

  • Loss of sensation:

A person does not perceive pain in denervated tissues, thus does not shift to remove the damaging pressure.

  • Reduction in movement:

Since many muscles are inoperative, a person tends to move less often.

  • Loss of collagen:

SCI person loss collagen due to multiple reasons this loss decreases mechanical strength of tissues.

  • Defective Vascularity:

Higher brains centers can can’t regulate vascular tone. The SCI person sometimes controls this tone inappropriately causing autonomic dysfunction tone.

  • Adrenergic nerve Pathway served:

The SCI person’s body does not have a proper hormonal response to stress.

  • Unsymmetric morphology:

Spinal curvature or pelvic obliquity yield unbalanced weight distributions.

  • Abnormal soft tissue:

Flaccid or spastic soft tissues yield unbalanced weight distributions.

3 Innovation Regarding Issue of Pressure Ulcer in UK & India

England and India are two countries spend a lot of finance and done lot of researchers to bring some innovation in pressure ulcer treatment  management  and facilitate patients as well  as their caregivers and have gained their trust, they discuss ideas on board for betterment their companies  do trade of medical products between two countries and have positive results

Rober attended  India’s largest healthcare exhibition Rober is delighted to be launching a range of pioneering mattresses, which replicate the body’s natural movements helping to eliminate pressure injuries and provide ultimate patient comfort and safety, at MEDICAL FAIR INDIA 2015 – India’s largest healthcare congress.

Pressure ulcers is a rising problem around the world not in England alone, the problem affects over 700,000 people a year and adds an additional £4,000 per ulcer onto each person’s care bill. Offering Indian hospitals a cost saving solution, zero pressure specialists Rober had created Airflex® Trio – an innovative mattress launched in India for the first time at the international congress. Airflex® Trio uses a clinically proven three cell cycle which response to a patient’s weight, spontaneous movement pattern and body posture, providing enhanced feasibility and complete pressure elimination at regular time intervals. (, 2015)

The ‘wave-like ripple effect’ allowed the body weight of the patient to be distributed evenly creating a comfortable but stable surface that doesn’t compromise on clinical outcomes.

The pressure ulcer specialist will also be presenting AirCaire® Duo to the Congress, an advanced two cell cycle overlay mattress that combines state-of-the-art pressure control technology.

The innovative mattress provides enhanced comfort and complete pressure elimination at regular intervals. It has integrated sides to aid patient safety and has variable pressure options to cater for patients of all sizes up to 180kg.  The amazing part is that it also has an inbuilt Cardio Pulmonary Resuscitation (CPR) valve, which provides quick deflation in the case of an emergency. England and India are two countries have much better, must said that they are very concerned about making their healthcare system error free and somehow they are successful and are exemplified in many other underdeveloped countries, their researchers are kept on working for more better management of pressure ulcers their physician are more concerned to take their patient’s towards fast recovery, but if someone ask to talk comparatively about both the UK is bit better than India but still their treatment management is excellent.

4. Proposed Change Method and Assessment Rationale:

The ongoing task is to re-audit and to see whether care has improved in comparison with your previous results. Clinical audit is a continuous process and you will need to continue to measure practice against the audit criteria at regular intervals. You may choose to monitor care more frequently to track your progress as care is improved. Incidence and prevalence are two ways to measure pressure ulcer frequency.

‘Incidence’ is the rate at which people initially admitted without an ulcer develop one during a specific period of time. This may be determined by the type of patients admitted – for example, those at high risk – and the effectiveness of preventive care (RCN 2001).

‘Prevalence’ is the proportion of people with pressure ulcers in a defined period of time. This is affected by, for example, people admitted with existing ulcers, patient healing rates, rates of discharge and successful treatment (RCN 2001).

For the pressure ulcer risk assessment and prevention national pilot audit project – for which this implementation guide was developed – two audit tools have been developed and these are included at the end of part two of this guide.

It is essential that you establish a program of regular clinical audit in order to maintain the high standards you achieve. As staff change and other issues compete for people’s attention, it is easy to lose the momentum necessary to sustain clinical excellence.

Clinical interventions typically target the magnitude and/or duration of loading. Pressure magnitude is managed by the selection of support surfaces and postural supports as well as body posture on supporting surfaces. Duration is addressed via turning and weight shifting frequency as well as with the use of dynamic surfaces that actively redistribute pressure on the body surfaces. Preventative interventions must be targeted to both magnitude and duration and addresses the rationale behind several common clinical interventions–some with more scientific evidence than others. The management of any pathology is health care system is done with great care every member of healthcare team is keeping about patient recovery and to touch accuracy levels so is the case with this pathology discussed here, once implementation of decided management is done and it shows positive outcomes it’s ok and healthcare system will approve it for further use, well if anomalies are seen than innovations are done for betterment of healthcare system and for avoiding fatalities in future. Same is cycle in case of pressure ulcer once approved management is done which is approved from health care system and still patient is not on track to recovery after assessment, innovations done such as prescription is changed, living style can be altered, nutrition charts should be given, proper physical care is advised to everyone who is in direct contact with patient including patient himself and his caregivers so these are few strategies done after assessment and may be after few errors detect in current management . These steps are changed for betterment.


Implementing an evidence-based pressure ulcer prevention program can reduce the occurrence of hospital-acquired pressure ulcers as well as pressure ulcer from any source having any possible epidemiology as it is not something not curable throughout the world, treating ulcer was illusion once but it’s quite practical now. But to sustain such improvement and to have possible positive outcomes, acute care facilities must implement preventive practices efficiently and consistently, knowledgeable staff should be over the patient based on physician-pharmacist nurses and all caregivers.  The success of professional efforts indicates that it’s possible to change a hospital’s culture such that pressure ulcer prevention becomes a lasting priority. Elements that contributed to that success included strong leadership, keenness of caregivers dedicated nurse and physician involvement, excellent prescription, an attitude of personal responsibility, improved documentation and communication, Ongoing education, and a portfolio of low-tech changes to practice. These elements can be engendered.

In the United States alone, the wound care market generates an annual revenue of $10 to $15 billion, depending on which products and services are included.50 These figures underscore the impact wound healing technology has made, and shed light on the overwhelming number of people requiring wound care and the enormous costs associated with treatment. Continued research, clinical trials, and cost analysis should be forthcoming on the subject of wound care, including negative pressure wound therapy.Pressure ulcer treatment is costly, although the exact costs have not been definitively demonstrated; it is unlikely that they will ever be precise given the diversity of the individuals requiring care. However, continued diligence toward cost-efficient wound care depends on further research. Multiple cost-analysis projects are under way in an effort to validate previous studies that have suggested the cost effectiveness of negative pressure wound therapy. In addition, multiple clinical trials are ongoing to more definitively delineate care of patients with pressure ulcers who are being treated with negative pressure wound therapy.

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