Pressure sores (decubitus ulcers)

Overview:

• These occur in the:
• Elderly
• Immobile
• Unconscious
• Paralysed
• They are due to skin ischaemia from sustained pressure over a bony joint, most commonly the heel and sacrum
• Normal individuals feel the pain of continued pressure and, even during sleep, movement takes place to change posture continually
• 70% of pressure sores occur in hospital
• 70% appear in the first 2 weeks of hospitalisation
• 70% are in orthopaedic patients (especially those on traction)
• 80% of patients with deep ulcers involving the subcutaneous tissue die in the first 4 months
• Altered sensation of the skin increases the risk of ulceration, and patients with diseases that affect the circulation and tissue nutrition are also predisposed, e.g.:
• Rheumatoid arthritis
• Diabetes mellitus
• Peripheral vascular disease

• General illness, anaemia, malnutrition and oedema may affect skin breakdown
• Other predisposing factors include:
• Anaesthesia
• Surgery
• Sedation
• Dehydration
• Urinary incontinence
• Faecal impaction

• The early sign of red/blue discolouration of the skin can lead rapidly to ulcers in 1-2 hours
• Leaving patients on hard A&E trolleys, or sitting them in chairs for prolonged periods, must be avoided

Management:

General measures should include identifying at-risk patients. Those with non-fading marking of the skin on pressure sites need immediate attention. The following are used in management:

• Bedrest with pillow to keep pressure off bony areas (e.g. pelvis and heels)
• Regular turning, but avoid pressure on hips
• Fleece over lower 1/3 of bed for heels
• Roto cushions for patients in wheelchairs
• Treatment of general circulation
• Special mattresses and beds to relieve pressure areas
• Topical treatment:
• Keep ulcer clean and moist
• Many topical therapies are HARMFUL

• Pain relief (may need diamorphine)
• Plastic surgery