Decubitus Ulcer

Question 1

Decubitus ulcer

Answer 1

A localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear

Question 2

Risk factors:

Answer 2

Decubitus ulcer risk factors:
1. Immobility

2. Nutrition
3. MS – altered MS, sedation, depression
4. Long procedures – valve replacements
5. Incontinence
6. Factors that prevent healing – DM, HTN, HF

Question 3

Clinical manifestations

Answer 3

Can present with local signs of soft tissue involvement, such as warmth, erythema, local tenderness, purulent discharge, and malodor

Can present with systemic infection – fever, increased WBCs

Reservoir for resistant organisms – MRSA, VRE

Question 4

Staging

Answer 4

STAGES:
Stage I – Intact skin with nonblanchable redness in a localized area (usually over a bony prominence) that may be painful, firm/soft, warm/cool compared to adjacent tissue; Darkly pigmented skin may not have visible blanching, but its color may appear different from the surrounding areas

Stage II – Partial-thickness dermal loss; Presents as a shiny/dry shallow open ulcer with a red-pink wound bed, without sloughing/bruising, or as an intact or ruptured serum-filled blister

Stage III – Full-thickness dermal loss; subcutaneous fat may be visible, but there is NO exposed bone, tendon, or muscle

Stage IV – Full-thickness skin loss with exposed bone, tendon, and/or muscle

Question 5

Medical management

Answer 5

1. Prevention – Movement, nutrition, constant monitoring and skin assessment
2. Treat as necessary – Wound care, surgery if needed
3. Assessment tool – Braden scale (HIGH score = Less likely to develop pressure ulcer)

Question 6

Nursing management

Answer 6

ASSESSMENT:

1. Immobility status – post-op, chronic conditions
2. Baseline – able to walk up one flight of stairs? perform ADLs?
3. Skin assessment – touch all areas
4. Settings that increase risk
5. Incontinence
6. Maintain nutrition status – albumin levels

PREVENTION:

1. Reduce risk – getting OOB, ambulation
2. Repositioning
3. Skin protectants for incontinent and immobile pts
4. Heel protectants
5. Pressure redistribution surface
6. Maintain nutrition – 30-35 kcal/kg/day; 1.25-1.5g/kg/day protein; and 1ml fluid/kcal/day

TREATMENT:

1. Low-air-loss or air-fluidized surface (stage 3-4 ulcers)
2. Establish bowel/bladder management programs
3. Cleanse wound and peri wound at each dressing change
4. Wound vacuum
5. Water can be used for cleaning wounds
6. Determine bacterial burden by tissue biopsy/C&S
7. Topical antibiotics
8. Systemic antibiotics – bacteremia, sepsis, advancing cellulitis, or osteomyelitis
9. Debridement
10. Determine modifications when reassessing
11. Alarming – smell, increased dimensions, reddened/darker/black, febrile

Question 7

Pt education

Answer 7

Promote:
1. Mobilization

2. Hydration
3. Self-monitoring to prevent recurrence – educate family
4. Minimize conditions that prevent healing – DM

Question 8

Care coordination

Answer 8

Wound team/nurse

Dietician

PT, OT