Decubitus Ulcers

Decubitus ulcers (pressure sores) are entirely preventable. They need not and should never occur. Factors predisposing to pressure sores are:

• Depressed sensory or motor function

• Altered consciousness

• Pressure over bony prominences

• Malnutrition

• Shearing forces

• Moisture (fecal and urinary incontinence)

The most common cause of decubitus ulcers is pressure, usually over bony prominences, in an individual with altered consciousness or impaired motor activity. When the pressure on soft tissue is greater than 32 mm of mercury, it closes capillary blood flow. This results in deprivation of oxygen to the tissue in this area and accumulation of metabolic end products. If these continue to accumulate for more than 2 h, there is irreversible tissue damage. The inability to shift one's body because of depressed sensory or motor function or unconsciousness leads to abnormal pressure and, thus, development of decubitus ulcers. The most common sites are the sacrum, the coccygeal areas, and the greater trochantars from lying in bed, as well as the ischial tuberosities if the patient is able to sit.

The second major cause of decubitus ulcers is malnutrition. This results in muscle atrophy and decrease in subcutaneous tissue, reducing the padding over the muscles, making the pressure more significant and producing ulcers. Obesity also contributes to pressure ulcers. A normal amount of fat protects the skin by acting as a cushion. Large quantities of fat, however, lead to ulceration because the adipose tissue is poorly vascularized and the underlying tissue then becomes more susceptible to ischemia.

Another major factor causing ulcers is shearing forces. Here, there is sliding of one tissue layer over another with stretching and angulation of blood vessels, which results in injury and thrombosis. This commonly occurs when the head of the bed is raised too high and the individual's body tends to slide downward. Friction and perspiration cause fixation of the skin and the superficial fascia to the sheets, while the deeper fascia slides down. Shearing forces in the elderly are aggravated by the loose skin common in the elderly because of loss of subcutaneous tissue and dehydration.

Moisture, usually caused by urinary and fecal incontinence, is also a major factor predisposing to development of pressure sores. Moisture reduces skin resistance to the other factors and increases the possibility of decubitus ulcers fivefold.

Decubitus ulcers (pressure sores) are divided into four (4) stages based on their clinical appearance and extent.

Stage 1 — The initial lesion seen following compression of skin and tissue is reactive hyperemia (reddening of the skin). The redness is caused by sudden increase in blood flow to the area compressed, after relief from the pressure of compression. If there is no injury to the tissue, the redness will disappear in less than 1 h. If the compression is long enough to produce ischemia but not irreversible injury, then you have an abnormal reactive hyperemia, which can last several hours. If the pressure is maintained long enough, one then has a stage 1 pressure sore manifested by erythemia that lasts longer than 24 h, does not blanch on pressure, and shows induration of the tissue caused by edema. These sores can occur in a matter of a few hours. In our opinion, while stage 1 pressure sores are an indication of a potential problem, they do not in themselves indicate neglect. They are readily treatable and should not progress.

Stage 2 — These range in severity from a blister to ulceration of the skin. They may involve the full thickness of the skin but do not penetrate into the subcutaneous fat. These lesions are in a grey zone as indicators of neglect. They shouldn't occur, but do. They are readily treatable.

Stage 3 — These are full-thickness ulcers extending through the skin and subcutaneous fat up to the fascia. There is usually undermining of the skin. The base of the ulcer is usually necrotic, foul-smelling and infected.

Stage 4 — Here the ulcer extends down through the fascia into muscle, often to the bone. Osteomyelitis may develop (Figure 21.1).

Stage 3 and Stage 4 ulcers, in our opinion, indicate poor or lack of nursing treatment and thus neglect. Preventive measures involve basic nursing techniques. In bed, the patient should be turned or repositioned at least every 2 h; in wheelchairs, every hour. Adequate nutrition and hydration should be given; the skin must be kept dry by preventing patients from lying in their urine and feces; the head of the bed should not be raised to such a degree that the patient will slide down and, if necessary, extra padding over bony prominences should be provided. If a sore develops, the physician should be notified immediately.

The incidence of pressure sores in individuals in nursing homes varies from study to study. A conservative approximation is 7-8%. Tsokos et al. conducted a prospective study of 10,222 bodies coming to cremation in Hamburg,

Stage Decubitus
Figure 21.1 Stage IV decubitus ulcers

Germany, from various sources including nursing homes, hospitals and private residences. 6 Pressure sores were observed in 11.2% of the individuals. The distribution of the sores by grades was Stage 1-6.1%; Stage 2-3%; Stage 3-1.1% and stage 4-0.9%. Stage 3 and 4 sores were found principally on the sacrum (69.6%). Seventy-three percent of all Stage 4 sores were in individuals 80 years of age and older. For Stage 4 sores, the place of death was:

• 36.2%: senior citizen or nursing home

The site where the individuals developed the sores was not necessarily the same as where they died.

Both the presence of pressure sores and deaths caused by them are under-reported. The authors have reviewed hospital admission records of patients with pressure sores where the sores are not mentioned at all in the physical examinations by the physicians or in the diagnoses. Pressure sores are dismissed as inevitable by many physicians. In fact, there is no doubt that pressure sores can be successfully prevented by determining the patients at risk for development of sores, consistently monitoring them for development of sores and instituting prophylactic procedures to prevent their development. If sores develop, they can be effectively treated by conservative or surgical means.

Decubitus ulcers, Stages 2-4, lose both fluids and proteins. The more severe the lesion, the greater the loss. These open sores are invariably colonized by bacteria. The resultant infection can cause septicemia. The exact incidence of this complication is unknown, because many physicians fail to attempt to conclusively determine the source of a fatal septicemia in these patients.

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