Decubitus Ulcers

GENERAL PRINCIPLES

Epidemiology

Decubitus ulcers typically occur within the first 2 weeks of hospitalization and can develop within 2-6 hours. Once they develop, decubitus ulcers are difficult to heal and have been associated with increased mortality.⁵ The most important risk factors for the development of decubitus ulcers are immobility, malnutrition, reduced skin perfusion, and sensory loss.

Prevention

Prevention is key to management of decubitus ulcers. It is recognized that not all decubitus ulcers are avoidable. Preventative measures include the following:

• Advanced static mattresses or overlays should be used in at-risk patients.⁶

• Skin care includes daily inspection with particular attention to bony prominences including heels, minimizing exposure to moisture, and applying moisturizers to dry sacral skin.

• Nutritional supplements may be provided to patients at risk.

• Frequent repositioning (minimum of every 2 hours) is suggested.

• Multilayer foam dressings have been shown to reduce the rates of pressure injuries.⁷

DIAGNOSIS

National Pressure Ulcer Advisory Panel Staging:

• Suspected deep tissue injury: Localized area of purple or maroon intact skin or blood-filled blister because of damage of underlying soft tissue from pressure and/or shear.

• Stage I: Intact skin with nonblanching redness of a localized area usually over a bony prominence. Darkly pigmented skin may obscure findings.

• Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as a blister.

• Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible, but the bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

• Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

• Unstageable: Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

TREATMENT

Optimal treatment of pressure ulcers remains poorly defined. There is evidence to support the following:⁸

• Hydrocolloid or foam dressings may reduce wound size.

• Electrical stimulation may accelerate healing.

• Other adjunctive therapies with less supporting evidence include radiant heat, negative pressure, and platelet-derived growth factor. Topical agents (Santyl, Xenaderm) may optimize healing or lead to minor slough debridement.

Other Precautions

• Fall precautions should be written for patients who are at high risk of a fall (e.g., dementia, weakness, orthostasis). Falls are the most common accident in hospitalized patients, frequently leading to injury. Fall risk should not be equated with bed rest, which may lead to debilitation and higher risk of future falls.

• Seizure precautions, which include padded bed rails and an oral airway at the bedside, should be considered for patients with a history of seizures or those at risk of seizing.

• Restraint orders are written for patients who are at risk of injuring themselves or interfering with their treatment because of disruptive or dangerous behaviors. Physical restraints may exacerbate agitation. Bed alarms, sitters, and sedatives are alternatives in appropriate settings.