5.2.4 Pressure sore
Grading & Level of Importance: B
Pressure ulcer, decubitus.
Prevalence: 10% of hospitalized patients, 5% of patients requiring nursing care at home.
Pressure-induced defect of skin and subcutis.
Aetiology & Pathogenesis
Ischeamia caused by prolonged pressure over bony prominences in patients who are unable to move. Two hours of ischaemia are sufficient to induce a pressure sore. Diabetes mellitus, post cerebral infarct reduced mobility, polyneuropathies, severe obesity and cachexia are risk factors.
Signs & Symptoms
Initial livid or bruise-like colour changes over the pressure points, reduced capillary refill. This stage is reversible. Later ulcers develop, involving skin, subcutis, muscles and often extending to the bones. Fetid odour.
Typical sites: sacrum, trochanters, scapulae, heels, vertebral column, elbows, hands, back of head.
Stage I: Livid erythema (macule or patch), some capillary refill.
Stage II: Ulcer to dermis
Stage III: Ulcer with full thickness skin loss to subcutaneous fat
Stage IV: Ulcer with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone.
Laboratory & other workups
Imaging studies, possibly nutritional evaluation, exclusion of diabetes and polyneuropathy.
Biopsies of the ulcer margin and base should be taken after 8 to 12 weeks of ulcers without tendency to heal, primarily to rule out tumors. Biopsy should be taken especially before invasive measures.
If pressure is not relieved, relentlessly progressive. Risk of cellulitis and sepsis.
Progression, superinfection with mixed bacterial flora, often with anaerobes, cellulitis, sepsis, osteomyelitis.
Clinical findings, assessment of depth with probe. Debridement. Imaging studies. Assessment of risk factors.
Neuropathic pressure ulcer, ulcerated tumours, chronic infections with fistula formation, artefacts and injuries.
Prevention & Therapy
Prevention is most important.
In stage I the tissue damage is reversible. Immediate institution of pressure-relieving measurements. Protection of damaged skin. In stage II superficial tissue damage has occurred. Debridement of necrotic tissue and standard moist wound therapy. Appropriate antibiotic coverage.
In stages III and IV the actual extent of the tissue damage is often underestimated. Extensive debridement, resection of the overhanging wound edges, vacuum-assisted wound therapy, standard moist wound therapy. Pressure sores in stage III and IV often require reconstructive surgery.
Consider the potential impact of impaired nutritional status.
- Determine if each statement on the classification of decubitus ulcers is true or false:
- Statement 1 Decubitus ulcers do not develop in young otherwise healthy bed-ridden patients
- Statement 1 Measures to reduce pressure on the skin are essential for both prophylaxis and therapy of decubital ulcers
- Which are complications of decubitus ulcers?
- Which of these are mistakes when treating a decubitus ulcer?
- Which of these is not a risk factor for decubitus ulcers?
- What type of lesion do you see in the picture?
- Which of these measures is the basis of care for decubitus ulcers?
- Which diagnosis best fits this picture?
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