Pressure Ulcers and Infection

Question 1

What is stage 1 pressure ulcer?

Answer 1

Stage 1: intact skin w non blanchable erythema

• Usually over a bony prominence
• Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area
• Area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue
• May indicate “at-risk” persons

Question 2

What is stage 2 pressure ulcer?

Answer 2

• Loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough or bruising*
• May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister
• This category or grade should not be used to describe tears, tape burns, incontinence associated dermatitis, maceration or excoriation
• Bruising indicates deep tissue injury. Slough.

Question 3

What is stage 3 pressure ulcer?

Answer 3

Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed

Slough may be present but does not obscure the depth of tissue loss

May include undermining and tunnelling

Depth of a Category or Grade 3 pressure ulcer varies by anatomical location:

• Bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue 🡪Grade 3 ulcers can be shallow
• In contrast, areas of significant adiposity can develop extremely deep Category or Grade 3 pressure ulcers

Bone/tendon is not visible or directly palpable

Question 4

what is stage 4 pressire pf i;cer?

Answer 4

full thickness loss of tissue, exposure to bone (osteomyelitis)

With exposed tendon or muscle

Slough or eschar may be present

Often includes undermining and tunnelling

Depth of Category or Grade 4 pressure ulcer varies by anatomical location:

• Bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow
• Category or Grade 4 ulcers can extend into muscle and/ or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur

Exposed bone/muscle is visible or directly palpable

Question 5

what are the risk factors of getting an infected pressure ulcer?

Answer 5

Limited mobility, poor nutrition, incontinence, age, DM, stroke, white race, abnormal skin, male, external factors: pressure,friction,shear, moisture

Question 6

how does one investigate an infected pressure ulcer?

Answer 6

• Do not perform cultures of pressure ulcers if s/s of infection absent (i.e. fever, WBC, surrounding cellulitis, purulence)
• Gold standard for 73% of dx: bone biopsy (73% of histologically proven OM will have + Cx)
• Radiology can be adjunct for diagnosis: MRI (others : Plain films, CT, Bone scan)

Question 7

How to treat pressure ulcer?

Answer 7

1. Off loading pressure
2. Improve nutritional status
3. Infection
   - Antibiotics for acute soft tissue infection
   - In general prolonged courses of antibiotics for chronic osteomyelitis not curative without debridement, or plans for coverage (e.g. flaps or meticulous care and Vac dressings, and self-healing if that is possible)