Decubitus Ulcers

Question 1

Skin lesions can be caused by

Answer 1

-Pressure
-Friction
-Shearing forces

Question 2

Factors

Answer 2

-Sensory/motor loss due to neurological disorders- person high risk
-May not notice + don’t take action
-May not be able to physically change position (motor)

Question 3

Lesions commonly occur

Answer 3

Over bony prominence
~sacrum, ischial tuberosity, greater trochanter, spinous processes, calcaneus, elbow

Question 4

Decubitus ulcers
Stage 1

Answer 4

●Local erythema, followed by warmth + hardened swelling over fragile but intact area
●Usually redness will diminish upon release of pressure if redness not resolved within 30 minutes may indicate pressure sores
●Edema + erythema are reversible but requires intervention

Question 5

Decubitus ulcer
Stage 2

Answer 5

●More tiss affected, epidermis to dermis
●Partial thickness
●Blister, abrasion or shallow ulcer maybe present
●Area moist, pink, Painful

Question 6

Decubitus ulcer
Stage 3

Answer 6

●Full thickness, skin loss down to subcutaneous layer
●Cavity is created with exudate + crust forming
●Crust or eschar is thick + leathery necrotic tissue

Question 7

Decubitus ulcer
Stage 4

Answer 7

●Full thickness wound with damage + necrosis into under lying mm + bone
●Deep Cavity that may be covered with eschar
●May lead to sepsis