Decubitus Ulcer Is an inflammation, sore, or ulcer in the skin caused by constant pressure on body tissues, or from an injury due

to friction or sheer force. The pressure or injury decreases the blood flow to the tissue, which results in further damage or even tissue death Most frequently over a bony prominence, also on the sacrum, elbows, heels, outer ankles, inner knees, hips, shoulder blades, and occipital bone of high-risk patients, especially those who are obese, elderly, or suffering from chronic diseases, infections, injuries, or a poor nutritional state. It results from ischemic hypoxia of the tissues caused by prolonged pressure on them. Pressure ulcers are most often seen in aged, debilitated, immobilized, or cachectic patients. The sores are graded by stages of severity. Prevention of pressure ulcers is a cardinal aspect of nursing care. The Latin "decubitus" (meaning lying down) is related to "cubitum" (the elbow) reflecting the fact the Romans habitually rested on their elbows when they reclined. Terminology Descriptions of pressure ulcers exist from as early as 3000 B.C, but the bulk of the literature on this problem has been published since World War II, when this complication developed in immobilized casualty victims. Original terminology used the expression 'bedsores' to describe ulcer formation; common medical terminology for this problem include decubitus ulcers, decubiti, and pressure sores. The word 'decubitus' is a Latin expression referring to a lying position which was first coined by French physicians and nurses in the 1700's. 'Pressure ulcer' is now the preferred medical term, since it hints at the central pathophysiological process behind ulcer formation. The impact of pressure ulcers is staggering. First and foremost, these wounds are very painful, thus causing patients a great deal of suffering. The anatomical location of the ulcer may result in a loss of dignity. Quality of life is affected as the patient must alter activities to help heal the wound or may face long-term hospitalization. A non-healing ulcer is at high risk for infection, which can be life-threatening. Ulcer treatments may require surgical procedures such as debridement, colostomies, and amputations, which the patient would otherwise not have to face. An ulcer that heals forms scar tissue, which lacks the strength of the original tissue and is more easily ulcerated again and again. Most importantly, the presence of a pressure ulcer increases the risk of death. Nearly 60,000 hospital patients in the United States are estimated to die each year from complications due to hospital-acquired pressure ulcers (IHI, 2007)
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Risk factor Major physical factors leading to formation of ulcers are pressure (intensity, duration, tissue tolerance), shear forces (can be iatrogenic, for instance, when patients are moved by staff), friction (secondary to movement in bed), moisture (most often due to urinary and fecal incontinence) and nutritional debilitation. From head to toe, the bony prominences that are at highest risk for pressure ulcer formation are the occiput, scapulae, elbows, greater trochanter, ischial tuberosities, sacrum/coccyx, malleoli, and the heels. Two-thirds of all pressure ulcers occur in the pelvic girdle region of immobilized patients.
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Many important risk factors have been identified that are associated with the development of pressure ulcers.
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Advanced age increases susceptibility due to the direct changes to the skin that occur

with aging (decreased epidermal turnover, decreased surface barrier function, and decreased sensory perception), and due to the increased incidence of other medical illnesses which may result in prolonged immobility. Other risk factors of prime importance include the presence of fecal or urinary incontinence, diabetes, and the presence of a neurological deficit such as a hemeparesis in a stroke patient. Other less well described but interesting associated factors include hypotension (increased shunting from skin to other organs), poor psychosocial status (decreased mental energy, motivation, increased emotional stress), smoking, elevated body temperature, and certain comorbid medical illnesses (e.g. blood dyscrasias).

Stages of Sign and Symptoms Stage 1 Pressure Ulcer Symptoms The main sign of a Stage 1 pressure ulcer is an area of redness that doesnt temporarily blanch, or turn white, when the area is pressed by a finger. The ulcer may have a blue or purple tint in people with a medium to dark skin tone. A Stage 1 pressure ulcer just affects the outermost layer of skin, and there is little damage to the tissue. The affected area is irregular in shape, and the tissue of the lesion can feel spongy or firm. Other possible symptoms of this type of lesion include pain, tenderness, a burning sensation, itching, swelling and warmth over the affected area. Stage 2 Pressure Ulcer Symptoms A Stage 2 pressure ulcer is a deeper area of tissue destruction and skin loss that involves either the outermost layer of skin, the deeper layer of skin, or in both. This type of lesion looks like a blister, scrape or shallow crater in the skin. The pressure ulcer is painful and is surrounded by an irregularly shaped area of red or purple discoloration that may feel warmer than the surrounding skin.

Stage 3 Pressure Ulcer Symptoms A Stage 3 pressure ulcer involves tissue damage or tissue death that extends below the skin to the fatty tissue underneath. The ulcer looks like a deep crater with a distinct border. The border is the result of the outermost layer of skin thickening and rolling over the edge toward the bottom of the crater. This type of skin lesion may drain a clear, yellow or white liquid. A Stage 3 ulcer may hurt, but if nerves are damaged you may not feel any pain. This type of lesion may become infected.

Stage 4 Pressure Ulcer Symptoms A Stage 4 pressure ulcer is a large, deep wound with damage reaching the muscles, bones, tendons or joints. The wound may drain a foul-smelling white liquid. This type of pressure ulcer is usually infected. A Stage 4 ulcer can lead to serious complications, such as an infection in the bone called osteomyelitis or sepsis, which is an infection in the blood. Diagnostic Examination Blood tests to assess your nutritional status and overall health Tissue cultures to diagnose a bacterial or fungal infection in a wound that doesn't heal with treatment or is already a stage IV wound Tissue cultures to check for cancerous tissue if it's a chronic, nonhealing wound Complications of pressure ulcers include: Sepsis. Sepsis occurs when bacteria enters your bloodstream through the broken skin and spreads throughout your body a rapidly progressing, life-threatening condition that can cause organ failure. Cellulitis. This acute infection of your skin's connective tissue causes pain, redness and swelling, all of which can be severe. Cellulitis can also lead to life-threatening complications, including sepsis and meningitis an infection of the membrane and fluid surrounding your brain and spinal cord. Bone and joint infections. These develop when the infection from a pressure sore burrows deep into your joints and bones. Joint infections (septic or infectious arthritis) can damage cartilage and tissue, and bone infections (osteomyelitis) may reduce the function of your joints and limbs. Cancer. Another complication is the development of a type of squamous cell carcinoma that develops in chronic, nonhealing wounds (Marjolin ulcer). This type of cancer is aggressive and usually requires surgical treatment.

Preventive Measure Prevention is the mainstay of care for pressure ulcers. The most important strategy is to be aware of the potential susceptibility to the problem before it arises. Other important prevention strategies include ensuring the patient is provided with adequate nutrition, maintaining adequate hydration, keeping pain under control, use of pressure relieving/reducing surfaces (pressure relieving mattresses or beds), instituting a strict schedule for turning the patient, and encouraging mobility. Any complaints of pain or discomfort on the part of the patient, localized to a particular area, should be evaluated immediately. If an ulcer is discovered, it should be thoroughly examined and characterized. Ulcer characterization should include: ulcer location and size, ulcer stage, the depth of tissue involved, the condition of the wounds and the presence of underlining or tunneling, necrotic tissue characteristics, exudate characteristics, surrounding tissue conditions and wound healing parameters of granulation tissue and epitheliization.

Four Stages of Decubitus Ulcer

Pathophysiology

Management Relieving Pressure The first step in treating a sore at any stage is relieving the pressure that caused it. Strategies to reduce pressure include the following: Repositioning. A person with pressure sores needs to be repositioned regularly and placed in correct positions. People using a wheelchair should change position as much as possible on their own every 15 minutes and should have assistance with changes in position every hour. People confined to a bed should change positions every two hours. Lifting devices are often used to avoid friction during repositioning. Support surfaces. Special cushions, pads, mattresses and beds can help a person lie in an appropriate position, relieve pressure on an existing sore and protect vulnerable skin from damage. A variety of foam, air-filled or water-filled devices provide cushion for those sitting in wheelchairs. The type of devices used will depend on a person's condition, body type and mobility.

Removing damaged tissue to heal properly, wounds need to be free of damaged, dead or infected tissue. Removing these tissues (debridement) is accomplished with a number of methods, depending on the severity of the wound, your overall condition and the treatment goals. Options include: Surgical debridement involves cutting away dead tissues. Mechanical debridement uses one of a number of methods to loosen and remove wound debris, such as a pressurized irrigation device, a whirlpool water bath or specialized dressings. Autolytic debridement, the body's natural process of recruiting enzymes to break down dead tissue, can be enhanced with an appropriate dressing that keeps the wound moist and clean. Enzymatic debridement is the use of chemical enzymes and appropriate dressings to break down dead tissue.

Cleaning and dressing wounds Care that promotes healing of the wound includes the following: Cleaning. It's essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores are cleaned with a saltwater (saline) solution each time the dressing is changed. Dressings. A dressing promotes healing by keeping a wound moist, creating a barrier against infection and keeping the surrounding skin dry. A variety of dressings are available, including films, gauzes, gels, foams and various treated coverings. A combination of dressings may be used. Your doctor selects an appropriate dressing based on a number of factors, such as the size and severity of the wound, the amount of discharge, and the ease of application and removal.

Pharmacological and other intervention Pain management. Interventions that may reduce pain include the use of nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin, Advil, others) and naproxen (Aleve, others) particularly before and after repositioning, debridement procedures and dressing changes. Topical pain medications, such as a combination of lidocaine and prilocaine, also may be used during debridement and dressing changes. Antibiotics. Pressure sores that are infected and don't respond to other interventions may be treated with topical or oral antibiotics. Healthy diet. Appropriate nutrition and hydration promote wound healing. Your doctor may recommend an increase in calories and fluids, a high protein diet, and an increase in foods rich in vitamins and minerals. Your doctor may also prescribe dietary supplements, such as vitamin C and zinc. Muscle spasm relief. Muscle relaxants such as diazepam (Valium), tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen may inhibit muscle spasms and enable the healing of sores that may have been caused or worsened by spasm-related friction or shearing.