In order to understand how pressure ulcers occur, it helps if you understand the nature and interaction of your skin and circulatory system.

SKIN
Just like your heart, liver or kidney, your skin is an organ of your body.  The major function of your skin is to act like a wrapper or package to contain your skeleton and other organs.  Essentially, your skin has a protective function and is inherently strong, pliable and elastic – the ideal characteristics for a “wrapping” function.

THE CIRCULATORY SYSTEM

We all know about arteries and veins, the vessels that form a network of rivers carrying blood, pumped by the heart, to every part of your body.  In simple terms, your arteries transport oxygenated blood.  Veins return deoxygenated blood (blood with the oxygen replaced by carbon dioxide) back to your heart for circulation through your lungs where the oxygen is replenished.

We are now going to as you to get out an imaginary microscope and examine your circulatory system on a much smaller scale.  Our bodies are made up of billions of individual cells.  These living cells are bathed in a sea of fluids which contain oxygen, nutrients, hormones and wastes. The rivers of blood flow through this sea nourishing, cleansing and chemically balancing it.

The arteries themselves break down into much smaller vessels, called capillaries, which are once cell thick and highly permeable.  This allows for the vital, life-giving exchange to take place between the rivers and the sea of intracellular fluids.

To continue our analogy, the capillaries can be compared to a barge moored alongside a quay where cargoes are swapped.  In this case, the cargoes are oxygen, carbon dioxide, nutrients, waste products, hormones and minerals.

One third of our bodies’ blood supply flows through our skin.  The blood nourishes the cells of the skin and removes waste, ensuring that our skin remains healthy and functional.

SKIN + CIRCULATORY SYSTEM + PROBLEMS = PRESSURE ULCERS

Put in simple terms, a pressure ulcer can develop because of reduced blood flow or because the “integrity” of the skin has been damaged.

It’s important to understand all the possible factors that contribute to creating a pressure ulcer.  We have already highlighted the most common, and therefore most important problem – pressure on the skin – which we will now explain in more detail.

PRIMARY CAUSE OF PRESSURE ULCERS:  DIRECT PRESSURE

 Direct pressure is caused by the weight of the body pressing the skin against a surface hard enough to slow or stop the flow of blood in the area.  If the surface is hard and particularly if pressure occurs over a bony, thin-skinned area, there is a definite risk of a pressure ulcer developing.

Shearing force
A person confined to a bed sliding slowly downwards from the sitting position best exemplifies this.  The consequent pulling or stretching of the skin can interrupt the blood supply to the skin.

Friction
Friction can be created when skin and sheets or bedclothes rub together.  This may happen when:

·         A person is pulled across rough or wrinkled sheets.

·         Food crumbs have not been removed.

·         Skin rubs against a body brace or traction device.

Loss of bowel or bladder control

Constant contact of the skin with urine or feces can contribute to rashes, skin breakdown or even infection

Perspiration
This is most often caused by inappropriate bedding, fever, garments and so on  Moisture contributes to skin breakdown through chafing and cracking of the skin.

Unhealthy skin
Disease, old age, poor circulation, skin dryness, lack of exercise, the use of irritating creams or ointments and improper humidity and temperature are all factors in contributing to unhealthy skin.  Some of these are out of your hands and only medical treatment can help, but there are some things you can do.  (We’ll go into more detail about this later in the section on skin care.)

Poor nutrition
General health and good skin integrity often depend on good eating habits.  There can be many simple reasons why a person is not eating properly.  Inappropriate plates and utensils, for example, or unappealing meals or a despondent attitude – these can all be factors.  If a pressure ulcer already exists, proper nutrition becomes even more critical.

Poor hygiene
A lack of planning or motivation, inappropriate undergarments, inconvenient facilities – the list of factors contributing to poor hygiene can be long.  Although it does require some effort, proper hygiene is one factor that can be controlled.

Old age
Let’s not forget the obvious:  with aging, major changes occur in the skin. For one thing, the amount of fat on the legs and forearms is usually reduced, cutting down on valuable padding and predisposing elderly patients to pressure ulcers. This is also why older people are more likely to complain of being cold. As we age, our sweat glands diminish in number, causing dry, itchy skin.

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