Pressure ulcers, also called decubitus ulcers, bedsores, or pressure sores, may occur initially in the superficial layers of the skin. The Agency for Health Care Policy and Research’s Pressure Ulcer Guideline Panel revised the classification of presure ulcers as follows: Stage I. Intact skin with non-blanching erythema (redness). Stage II. Shallow, open ulcer with red-pink wound bed. Ulcer is superficial and manifests clinically as an abrasion or blister. Stage III. Full-thickness tissue loss with visible subcutaneous fat. Ulcer manifests clinically as a deep crater with or without undermining adjacent tissue. Stage IV. Full-thickness tissue loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
Risk factors for pressure ulcers are classified as intrinsic or extrinsic. Intrinsic factors include limited mobility, poor nutrition, comorbidities, and aging skin. Extrinsic factors include pressure, friction, shearing force, and moisture.
A patient who stays in one position without relief of pressure, especially over bony prominences, is significantly at risk. Incontinence, which may cause continual contact of his skin with feces and urine, may cause chemical irritations, resulting in impaired skin integrity. If the patient is bedridden, he should be repositioned every two hours. To minimize shear, the head of the bed should not be elevated more than 30 degrees. He may be able to reduce pressure by repositioning himself using manual aids, such as a trapeze bar. You may also look into pressure-reducing devices that can reduce pressure or relieve pressure. A dietitian consultation and the use of skin moisturizers are considereed reasonable preventive measures.
The presence of a pressure ulcer may indicate inadequate services or support. Assess the size and depth of the ulcer, the amount and color of any exudate, the presence of pain or odor, and the color of the exposed tissue. Make sure that the patient is receiving intensive support services. You may also consider assistance with lifting and turning the patient.
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