Ulcer Management
- Where is the most common location for decubitus ulcers?
- What are the distinguishing characteristics of a decubitis ulcer?
- What are the risk factors for the formation of decubitis ulcers?
- What is the accepted method of treatment for decubitis ulcers?
- How do you classify decubitis ulcers?
- What is the average healing time for decubitis ulcers?
- How do you know if a decubitis ulcer is infected?
- What are the three most common reasons for not healing?
- What type of dressing do you put on a decubitus ulcer?
- Should decubitus ulcers be debrided?
Decubuitus/Pressure Ulcers
The heel (posterior lateral and medial), malleolar, patellar, and pretibial areas are the most frequent lower extremity locations for pressure ulcer formation. These make up only 25% of all pressure sores. The ischial tuberosity, scapula, trochanteric, and sacral areas are the most common.
A study of interface pressure for pressure reduction and relief mattresses.
J Enterostomal Ther. 1990 Sep-Oct;17(5):212-6. No abstract available.
PMID: 2212246 [PubMed - indexed for MEDLINE]To top
What are the distinguishing characteristics of a decubitis ulcer?
Location is the most distinguishing characteristic of decubitus ulceration. History of prolonged immobilization helps confirm the diagnosis. The length of time pressure is applied to the area will determine its appearance/developmental stage. It will initially look similar to an abrasion, ill defined, irregular, indurated, and erythematous. This is due to a pressure exceeding the capillary filling pressure (32 mmHg), sheering forces, friction, and maceration to the area. If untreated, the ulcer will progress to the dermis, subcutaneous tissue, deep fascia, and then to muscle or bone. Tissue necrosis and ulceration may begin in as little as 2 hours if the pressure is constant.
What are the risk factors for the formation of decubitis ulcers?
Immobility is primary risk factor for the formation of decubitus ulcers. Two hours of constant pressure is enough time to start an ischemic event and cause ulceration. Factors noted in the AHCPR Guidelines for at risk individuals include immobility, incontinence, nutritional deficits, advanced age, impaired perception or sensation, predisposing health problems and altered levels of consciousness. Patients in the acute care hospital setting are at a notably greater risk. Malnutrition may also be linked to the development of your patient?s decubitus ulcer.
Norton D. Calculating the risk: Reflections on the Norton Scale. Decubitus. 1989; 2: 24-31.
Bergstrom N, Braden BJ, Laguzza A, Holman V.
The Braden Scale for Predicting Pressure Sore Risk.
Nurs Res. 1987 Jul-Aug;36(4):205-10.
PMID: 3299278 [PubMed - indexed for MEDLINE]
Gosnell DJ. Pressure sore risk assessment: A critique. Part I: The Gosnell scale. Decubitus. 1989; 2 (No. 3): 32To top
What is the accepted method of treatment for decubitis ulcers?Your initial and most important treatment is to relieve pressure over bony prominences. Nursing &/or home care, which often facilitate your patient?s care, are critical in the prevention and treatment of pressure ulceration. Pillows may be placed behind the calves to keep the heel floated when the patient is in the bed and foam foot cushions may be used for their feet when in the wheelchair. The patient should wear a mulitPodus boot, which completely off-weights the plantar and posterior medial/lateral heel, when they are not walking.
Treatment is largely based upon the stage of your ulcer. Stage I decubitus ulcers should be assessed for risk as they have only begun to ulcerate and complications may be avoided if causative factors are removed. When treating the wound directly, one of your most valuable tools is your constant assessment of the ulcer. The changes in the ulcers edges, type and amount of necrotic tissue, peri ulcer skin color, granulation and epitheliaziation should all be noted frequently and meticulously. The wound bed must remain moist while the periulcer area remains dry to avoid maceration. In patients with a solid vascular status and an ulcer that does not track to tendon or bone, fibrous or devitalized tissue may be removed to maintain a largely granular base. Dead space should be avoided in these wounds and may be packed with wet sterile gauze and should be changed daily (note that studies differ). Patients who present with an ulcer with an overlying stable eschar should be left alone, while patients with a fluctuant and notably infected eschar should be debrided and treated for underlying infection. Topical growth factors may be used in stage III-IV ulcers.
Air-fluidized beds, low-air-loss beds, thick foam mattresses, water mattresses, alternating-pressure air mattresses, and static multi-layered air mattresses are beneficial for patients with multiple, large and deep ulcers and those patients which are functionally dependent.
Houghton PE, Kincaid CB, Campbell KE, Woodbury MG, Keast DH.
Photographic assessment of the appearance of chronic pressure and leg ulcers.
Ostomy Wound Manage. 2000 Apr;46(4):20-6, 28-30.
PMID: 10788924 [PubMed - indexed for MEDLINE]
Maggot versus conservative debridement therapy for the treatment of pressure ulcers.
Wound Repair Regen. 2002 Jul-Aug;10(4):208-14.
PMID: 12191002 [PubMed - indexed for MEDLINE]
Ann Intern Med. 1995 Sep 15;123(6):433-42. Review.
How do you classify decubitis ulcers?
In 1989, the National Pressure Ulcer Advisory Panel sponsored a National Consensus Conference, during which a classification system (below) was devised combining several commonly used staging systems.
National Pressure Ulcer Advisory Panel (NPUAP) Staging System for Pressure Ulcerations
| Findings | Stage |
| nonblanching erythema of intact skin | I |
| partial-thickness skin loss involving the epidermis dermis or both. The ulcer is superficial and may appear as an abrasion blister or shallow crater. | II |
| Full-thickness skin loss involving damage or necrosis to subcutaneous tissue, which may extend down to but not through underlying fascia. The ulcer may appear as a deep crater with or without undermining of adjacent tissue. | III |
| Full-thickness skin loss with extensive destruction tissue necrosis or damage to muscle bone or supporting structures such as joint capsule | IV |
National Pressure Ulcer Advisory Panel. Pressure ulcers prevalence cost and risk assessment: consensus development conference statement. Decubitus. 1989; 2: 24-28.
Shea JD. Pressure ulcers. Clin Orthopaedics Related Research. 1975; 112: 89-100.
Kanj LF Wilking SVB et al. Pressure ulcers. J Am Acad Dermatol. 1998; 38: 517-536.
Yarkony GM Kirk PM et al. Classification of pressure ulcers. Arch Dermatol. 1990; 126: 1218-1219.
Stotts NA Rodeheaver GT et al. An instrument to measure healing in pressure ulcers: Development and validation of the Pressure Ulcer Scale for Healing (PUSH). J Gerontology: Medical Sciences. 2001; 56A: M795-M799.
What is the average healing time for decubitis ulcers?Healing time for decubitus ulcers varies based on stage of the ulcer, size, co-morbidities and location.
Using the stages noted by the NPUAP system.
| Stage I | 14 days |
| Stage II | 45 days |
| Stage III | 90 days |
| Stage IV | 120 days |
Another study shows that 42% of stage II to IV ulcers were completely healed at 6 weeks.
How do you know if a decubitis ulcer is infected?An ulcer that does not heal in a reasonable time period using conventional methods should be considered for infection. Colonization with bacteria does not denote an infected ulcer, as all pressure ulcers are chronically contaminated wounds. Fever, purulent exudates and erythema are all typical signs of infection. Do not confuse cellulitis with the erythema and reactive hyperemia associated with normal healing. You must rule out osteomyelitis when you see purulent drainage that extends to bone. Foul odor may be an indicator if your ulcer is colonized with anaerobic or gram negative organisms. A patient that presents with fever, confusion, hypotension, and a stage III-IV ulcer, without any other notable cause, should be considered infected and septic.
Pressure ulcers in the nursing home.
Ann Intern Med. 1995 Sep 15;123(6):433-42. Review.
PMID: 7639444 [PubMed - indexed for MEDLINE]
While the negative predictive value that x-rays have for decubitus ulcers is quite useful, the positive predictive values tend to be less useful. Abnormal x-rays may be seen in the surrounding tissues of non-infected ulcers as well as infected ones.
When ruling out osteomylitis, your bone biopsy and MRI are always necessary.
What are the three most common reasons for not healing?Improper offloading, underlying infection and an ischemic component are common reasons for not healing.
What type of dressing do you put on a decubitus ulcer?All dressings for decubitus ulcers should maintain a moist ulcer environment. This promotes the migration of fibroblasts and epithelial cells and allows the growth factors present in the serous exudate to increase healing. You may cleanse a wound that is expected to heal with a non-cytotoxic fluid like saline. Betadine is cyto toxic and will kill granulation tissue.
Dressings for decubitus ulcers are categorized by their affect on moisture in the wound environment.
For a draining ulcer: Polyurethane foams (Lyofoam, Allevyn, NudermNu-Derm, FlexanFlexzan), Alginates (Kalostat, Sorbsan), and Hydrogels (IntraSite, ElastoGel, ClearSite, Aquasorb).
For a dry ulcer: Hydrocolloid wafers (DuoDerm, Comfeel, TegabsorbTegasorb, Restore) and Thin films (OpSite, Tegaderm).
A wet to moist dressing of cotton guaze and saline is quite suitable for many decunitus ulcers. This is another means of mechanical debridement.
Should decubitus ulcers be debrided?Debridement of a decubitus ulcer is dependent upon the secondary morbidities of the patient (i.e. ischemia, age), the infectious/non-infectious state, and the depth of the ulcer. Debridement may be:
Mechanical- (Stage II)- Gentle debridement via removal and reapplication of saline moistened gauze. This type of debridement removes both healthy and devitalized tissue.
Autolytic- (Stage II)- Moisture retentive dressings (hydrocolloids) hydrate necrotic tissue, which allows the body?s WBCs and enzymes to bathe the ulcer and digest the necrotic tissue. This method only removes unwanted tissue.
Chemical- Prescriptive enzymatic debriding agents perform in a moistened environment to void the wound of necrotic tissue. It will not remove eschar, therefore surgical debridement is necessary if an unstable eschar is present.
Surgical- (Large Stage III and IV)- Sharp instrumentation will remove the necrotic tissues. This method is effective in infected and extensively necrotic ulcers.