DECUBITUS ULCER /

PRESSURE SORES

Reddened areas, sore, or ulcer of the skin
over bony prominences d/t impaired
blood circulation to tissues leading to
localized ischemia.
back of head / occiput, scapulae / shoulder
blade, sacrum, buttocks, and heels of the
feet

CAUSES:
1. Pressure - primary cause; compressing
downward force to the skin by gravity
2. Friction rubbing; force parallel to skin
3. Shearing force pressure & friction

RISK FACTORS:
1. Most common risk factor: Prolonged
immobility / inactivity / bed rest
2. Most significant factor: Length of time
bony prominences are exposed to
pressure
3. Bowel or Bladder Incontinence
involuntary defecation or urination;
moisture causes maceration
4. Edema decreased elasticity, resilience,
and vitality of skin, prone to skin
breakdown and causes circulatory
impairment.
5. Malnutrition causes weight loss, muscle
atrophy, and loss of subcutaneous tissue,
more prone to injury.
6. Anemia decreased o2 carrying capacity
of hemoglobin; <RBCs; increased body
heat increased metabolic rate
increased 02 requirements of cell o2
deficit
7. Decreased Mental Status (Dementia,
Delerium) unable to recognize
discomfort of pressure
8. Diminished Sensations unable to
perceive pressure

ESCHAR
Black wound; dead tissue that sloughs
off the healthy skin
Crust formation w/o blood supply

STAGES OF PRESSURE SORE
FORMATION
staging reflects depth of tissue exposure
If theres necrotic tissue, you wont be able
to determine the stage unless wound base
is seen.

Stage 1
Skin Redness
Non blanching macule of intact skin that
returns to normal colour after 15 20
minutes of pressure relief.
.
Stage 2
Blister Formation
Partial thickness skin loss of epidermis
and dermis
Superficial (shallow) ulcer / blister /
abrasion with PINKISH RED BASE and
WHITE OR YELLOW ESCHAR

Stage 3
Full thickness skin loss / Deep Ulceration
that affects epidermis, dermis, and
subcutaneous tissue with WHITE OR
YELLOW ESCHAR
Purulent drainage is common

Stage 4
Full thickness skin loss/ Deep Ulceration
that affects MUSCLES and EXPOSES
THE BONE with BLACK OR BROWN
ESCHAR
Foul smelling purulent drainage

PREVENTION OF PRESSURE SORES
Reposition client every 2 hours.
Provide smooth, clean, dry bed &
beddings.
Use foam, rubber pads, artificial
sheepskins, egg crate mattress under
pressure areas.
Assess skin for early S/S and provide
meticulous skin care before and after
positioning. Keep skin clean and dry.
Avoid massaging bony prominences with
soap when bathing
Client teaching on prevention of pressure
sores.

TREATMENT OF DECUBITUS ULCER
Wet-to-dry dressing for mechanical
debridement (removal necrotic tissue)
Clean and dress sore using surgical
asepsis
Clean pressure sore daily, preferably in a
whirlpool bath.
If pressure sore is infected, obtain sample
of drainage for culture & sensitivity test
Keep HOB flat or elevated at max of 30
degrees.
Encourage ambulation or sitting in
wheelchair
Provide ROM (range-of-motion) exercises.