Pressure Ulcer

BASICS

Definition: Localized skin/tissue breakdown due to prolonged pressure/shear, usually over bony prominences (sacrum, calcaneus, ischium).
Synonyms: Bedsores, decubitus ulcers, pressure sores/injuries/wounds/points, ischemic ulcers.
Classification:
Stage I: Nonblanchable erythema, intact skin.
Stage II: Partial-thickness loss, red-pink moist wound or serum-filled blister.
Stage III: Full-thickness loss, fat visible, no exposed bone/tendon/muscle.
Stage IV: Full-thickness loss, exposed bone/tendon/joint.
Unstageable: Depth unknown, base covered by slough/eschar.
Suspected deep tissue injury: Purple/maroon area or blood-filled blister.

Main cause: External pressure/shear/friction/moisture → impaired perfusion → tissue necrosis.
Risk factors:
Immobility
Malnutrition
Poor perfusion
Sensory loss
Medical devices

Full skin exam, repeated regularly
Assess site, stage, size, sinus tracts, undermining, tunneling, exudate, necrosis, odor, granulation
Identify barriers to healing (infection, perfusion, sensation)

Venous, arterial, diabetic, neuropathic, and hypertensive ulcers
Cellulitis, dermatitis, skin tears, intertrigo, cancer, pyoderma gangrenosum, vasculitis

Labs: CBC, CRP, albumin/prealbumin, electrolytes, BUN/Cr, HbA1c
Wound culture: Deep tissue/bone biopsy if needed (not surface swab)
Imaging: X-ray, MRI, or US for depth, bone involvement; ABI/Doppler for LE wounds

Comprehensive assessment, pressure redistribution, nutritional support, wound bed prep, infection/moisture control, pain management, goals of care

Cleanse, debride necrotic tissue
Dressings (transparent film, hydrocolloid, hydrogel, foam, silver/honey/cadexomer/alginate, etc.)
No clear evidence of one dressing superior to others
Enzymatic debridement for necrosis

Activated charcoal, topical antiseptics for refractory wounds
Electrical stimulation, electromagnetic field, or pulsed radiofrequency for recalcitrant cases
Negative pressure wound therapy (NPWT) for deep ulcers
Low/high-frequency ultrasound as adjunct
Hydrotherapy, maggot therapy, phototherapy (short-term UVC)

Pain control, diabetes management, physical therapy, patient/caregiver education
Refer wound care, vascular, plastic surgery, or dermatology as needed

Indications: Refractory cellulitis, osteomyelitis, systemic infection, advanced malnutrition, suspected abuse, inability to self-care
Dressings: 1–3 times daily
Monitor for new/changing wounds
Discharge: Improvement or safe plan/location

Regular wound assessment, measurement, and plan review (change plan if no progress in 2–3 weeks)
Encourage home health/nursing support
Patient education:
Skin checks, signs of infection/pain, prevention of new wounds
Skin care, moisture management, smoking cessation

Implement assessment/prevention for all at-risk patients.
Identify risk factors, maximize nutrition, reposition, regular skin checks, and treat wounds promptly.
Time-sensitive, patient-centered care is critical to optimal outcomes.