Pressure Sore

Introduction and Vulnerable Anatomical Areas

A pressure sore, also known as a bedsore, pressure injury, or decubitus ulcer, is localized damage to the skin and underlying soft tissue usually over a bony prominence. These injuries develop when constant pressure, friction, or shearing forces compromise blood supply to the skin, leading to tissue ischemia and necrosis. They represent a significant challenge in Nigerian healthcare settings, especially when caring for immobilized patients in under-resourced wards where nursing staff may be stretched thin.

Pressure points vary depending on the primary position of the client. When a patient lies strictly on their back, vulnerable sites include the occiput, shoulder blades, elbows, sacrum, and heels. Side-lying positions shift the risk to the ears, shoulders, greater trochanter of the hip, knees, and ankles. For individuals confined to a wheelchair, the ischial tuberosities, tailbone, and spine take the brunt of the body weight.

Causes and Pathophysiology of Tissue Breakdown

The fundamental trigger for tissue breakdown is prolonged mechanical pressure that exceeds capillary closing pressure, which typically ranges between 12 and 32 mmHg. When external pressure squeezes small blood vessels shut, oxygen and essential nutrients fail to reach the tissue cells, while metabolic waste products accumulate. If this state persists, cell death occurs.

Three main physical forces contribute to this process:

Pressure: Vertical force that compresses tissue against a hard surface, shutting off capillary blood flow.
Friction: Surface damage that occurs when skin rubs against bed sheets or rough clothing, stripping away the outer epidermal layer.
Shearing: A damaging mechanical force that happens when the skeleton slides downward while the skin remains stationary against the bed, stretching and tearing deep blood vessels.

Staging and Clinical Identification

Clinical assessment of pressure injuries relies on a standardized staging system that describes the depth of tissue destruction. Midwives must inspect the skin closely during routine bed baths and turning routines.

Stage 1: Intact skin with localized area of non-blanchable redness, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding tissue.
Stage 2: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister.
Stage 3: Full-thickness loss of skin, in which adipose fat is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough or eschar may be visible.
Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough or eschar may be visible.
Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

Prevention and Management Protocols

Preventing and managing pressure injuries requires a multi-faceted approach centered on relieving pressure, maintaining skin integrity, and supporting overall health. In many Nigerian hospitals where specialized pressure-relieving mattresses are scarce, low-cost alternatives such as water-filled gloves, foam wedges, and improvised pillows play a vital role in offloading vulnerable bony prominences.

Intervention Category	Key Action Steps
Positioning	Turn bedridden patients at least every two hours; avoid 90-degree side-lying to prevent direct pressure on the trochanter.
Skin Care	Keep skin clean and dry; use gentle cleansers; apply moisture barrier creams for patients experiencing incontinence.
Nutrition	Provide adequate protein and hydration to support tissue repair and maintain positive nitrogen balance.
Mobilization	Encourage active or passive range of motion exercises to stimulate local blood circulation.

Nursing Responsibilities and Patient Education

Midwives and nurses hold direct responsibility for risk assessment, daily skin surveillance, and coordinating multidisciplinary care. Utilizing a validated tool like the Braden Scale upon admission helps identify high-risk clients early so that preventative care plans can be implemented immediately.

Education remains a powerful tool involving both the patient and their family caregivers. Because family members often perform a significant portion of bedside nursing care in local healthcare environments, they must be taught how to spot early signs of skin redness, how to lift rather than drag a patient during repositioning, and why maintaining a protein-rich diet aids healing. Clear communication empowers families to partner effectively with the clinical team.

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