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Amputation Prevention in Black Populations: Tackling Pressure Ulcers

Pressure ulcers are a common problem among diabetics and patients with mobility limitations. Such wounds bring suffering to patients, reduce the quality of life, and can lead to amputation if left untreated. African Americans are 2 to 3 times more likely to undergo major lower extremity amputations than white patients, and tackling pressure sores could go a long way in lowering these numbers.

What Are Pressure Ulcers?

Pressure ulcers are localized damage to the skin and underlying soft tissue, which can be very painful. It occurs due to intense or prolonged pressure or a combination of pressure and shear. A pressure sore often develops on the skin above bony prominences; its location depends on the patient's sitting or lying position.

People with diabetes are at a higher risk of developing pressure ulcers because of their association with neuropathy – damage to the nerves that causes loss of sensation. Pulmonary artery disease (PAD), a resultant condition of diabetes, also contributes to pressure ulcers due to poor circulation. Patients with diabetic neuropathy may not notice pressure on the tissue and thus will not see the need to change position.

Tackling Pressure Ulcers in The Black Population

A Centers for Disease Control and Prevention (CDC) report estimates approximately 11.7% of Blacks diagnosed with diabetes compared to 7.5% of whites in the U.S. It follows that African Americans are most likely to get pressure ulcers at some point.

Research published in 2017 found a great health disparity in pressure ulcer healing for Blacks admitted to nursing homes. The Black residents were more likely to have advanced pressure ulcers than white residents. Another report attributes this finding to a majority of nurses having difficulty spotting non-blanching erythema – a risk factor for developing pressure sores – in dark skin. They proposed introducing an educational program to detect grade 1 pressure ulcers in Black patients for early treatment interventions.

Pressure ulcer prevention and management should focus on initial risk assessment and reassessments of patients, followed by a multi-pronged approach to tackle pressure ulcers in high-risk patients such as diabetics.

Risk Assessment and Reassessments

Pressure ulcers are a major health safety hazard that demands timely healing to prevent unnecessary amputations. There needs to be an initial pressure ulcer risk assessment for all patients exhibiting symptoms of non-healing wounds, followed by a daily reassessment that includes checking the skin, keeping the wound dry, and optimizing nutrition and hydration.

Pressure ulcers are staged according to the severity of skin loss. A stage 1 ulcer is a starting wound, whereas a stage 2 ulcer exhibits partial loss of skin layers that look like a scab, blister, or abrasion. These first two stages are considered minor forms of pressure ulcers. Advanced pressure ulcers happen in stage 3 or stage 4, whereby a full thickness of the skin is lost. In a stage 4 pressure ulcer, the underlying muscle or bone may be exposed.

Pressure Ulcers Treatment

Treatment for pressure ulcers should focus on promoting wound healing, increasing local drug concentration, and reducing adverse drug reactions. The first step should be eliminating the underlying cause – pressure. Stage 1 pressure sores heal on their own if the pressure is removed. In more advanced cases, the necrotic tissue is removed by debridement strategies.

Current treatment for pressure ulcers includes medicinal dressings, topical administration, and external disinfectants containing silver and iodine. Doctors may need to administer antibiotics if the surrounding tissue is infected. The wound and surrounding tissue must always stay clean to eliminate bacteria contamination.

Health care professionals involved in pressure ulcer treatment and preventive care at all levels must recognize the impact of pressure ulcers on patients' quality of life. The impact is long-term and depends on the patient's characteristics and wound stage. Therefore, there needs to be a multidisciplinary team of wound care and skin specialists to provide consultation and care tailor-made for each patient.

Prevention of Pressure Ulcers

The primary issue in preventing ulcers, especially in people with diabetes, should be controlling blood sugar. Extra attention should be paid to a patient bedridden for an extended period to reduce the long-term pressure on the body. Also, pillows or special pressurized mattresses can relieve pressure on sensitive areas.

Protective padding such as sheepskin applied to bony prominences may also help. More recently, patient monitoring (PM) systems that use wireless sensors are placed on patients to record position and movement.

Bottom Line

Damage from pressure ulcers can cascade into complications such as amputation, septic infection, and premature death. It raises costs of treatment and care and increases the risk of infections. Treatment of pressure ulcers involves managing infections, removing dead tissue, maintaining an optimal wound healing environment, and possibly surgery. Adequate nutrition, adhering to a repositioning schedule, and other preventative procedures can help reduce the risk of pressure ulcers in the Black population.

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