- Also called as decubitus ulcers.
- It is a localized ulceration of the skin and deeper structures.
- Most commonly results from prolonged periods of bed rest.
- Friction (causing abrasion of the stratum corneum) and shearing (sliding of adjacent surfaces causing rupture of capillaries) forces contribute to the destructive mechanism of pressure.
- Risk factors for pressure sores include bowel or bladder incontinences, malnutrition or significant weight loss, edema, anemia, hypoxia, hypotension, neurological impairment, immobility, and altered mental status.
- Complication includes tissue loss, infection, and sepsis.
- Presence of risk factors.
- Frequent observation of the skin, especially over pressure points.
- Staging of the pressure sore to initiate appropriate treatment:
- Stage I – nonblanching macule that may appear red or violet.
- Stage II – skin breakdown as far as the dermis.
- Stage III – skin breakdown into the subcutaneous tissue.
- Stage IV – penetrates bone, muscle, or joint.
- Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined
- No testing is usually indicated.
- Wound cultures are usually inaccurate due to bacterial contamination and colonization, but may be done to guide antibiotic therapy when signs of infection are present.
- Pressure must be relieved and maceration, friction and shearing forces avoided for wound healing to take place.
- Normal saline is used for routine cleansing once to several times daily depending on the amount of wound drainage, unless a protective dressing is used.
- Wet to dry dressings may be used to assist with mechanical debridement.
- Debridement of devitalized tissue may be necessary using scissors and scalpel following sterile technique.
- Protective wound dressings may be used to minimize disruption of migrating fibroblasts and epithelial cells and to provide moist, nutrient rich environment for healing.
- Debriding enzymes may be used for stage III to IV ulcers; may damage healthy tissue and are not appropriate for hard eschar.
- Topical antibiotics may be used to treat signs of local wound infection.
- Analgesics are usually needed, particularly 30 to 60 minutes before wound care.
- Monitor for signs of local infection (erythema around edges, foul odor, purulent exudates, poor healing) as well as sepsis (fever, cellulites around wound, increased pain, decreased blood pressure, tachycardia, altered level of consciousness).
- Assess size of pressure sore weekly in response to therapeutic measures; document the largest diameter, not just the surface diameter, and document the greatest depth.
- Monitor pain level and response to pain medication; in unresponsive patient, look for agitation, tachycardia and increased blood pressure to indicate pain.
- Use pressure0 reducing surface to help prevent pressure sores, but they are not effective in treating established pressure sores.
- Avoid elevating head of the bed more than 30 degrees to prevent shearing force as the patient slides downward against mattress.
- Encourage activity and ambulation as much as possible.
- Turn and reposition patient every 2 hours.
- Bathe patient as needed with a bland soap, rinse, and blot dry with a soft towel.
- Lubricate skin at least twice daily with a bland cream or gel, especially over pressure points.
- Employ bowel and bladder program to prevent incontinence.
- Avoid plastic coverings and poorly ventilated chair or mattress surfaces.
- Ensure that high protein, nutritious diet is provided, utilize supplements as necessary and ensure adequate fluids to hydrate skin.
- Clean pressure sore, as directed or per protocol; use normal saline or prescribed solution, irrigate as necessary to remove exudates, but do not disrupt healing tissue.
- Teach diet rich in protein, iron, and vitamin C to aid in full healing.