Decubitus Ulcer

Overview

Decubitus ulcers, commonly known as pressure sores or bedsores, are localized injuries to the skin and underlying tissue that result from prolonged pressure on the skin, typically occurring over bony prominences. These wounds represent one of the most significant complications of immobility and are largely preventable with proper care and attention. The term "decubitus" comes from the Latin word meaning "lying down," reflecting the condition's strong association with prolonged bed rest or immobility. These ulcers can develop within hours to days of sustained pressure, making them a critical concern in healthcare settings, particularly for patients with limited mobility.

The pathophysiology of decubitus ulcers involves a complex interplay of pressure, shear forces, friction, and moisture that compromises blood flow to affected tissues. When external pressure exceeds capillary perfusion pressure (typically 32 mmHg), tissue ischemia occurs, leading to cell death and tissue breakdown. The severity of these ulcers is classified into four stages, ranging from superficial skin damage to deep tissue involvement that may extend to muscle and bone. Early-stage ulcers may appear as simple skin discoloration, while advanced stages involve open wounds with significant tissue loss that can become infected and life-threatening if not properly managed.

Decubitus ulcers represent a significant healthcare burden, affecting millions of patients worldwide and contributing to increased morbidity, mortality, and healthcare costs. They are particularly common in elderly patients, individuals with spinal cord injuries, and those requiring long-term care. The development of pressure ulcers is often considered a quality indicator in healthcare facilities, as many are preventable with appropriate interventions. Understanding the risk factors, early recognition of symptoms, and implementation of comprehensive prevention strategies are essential for reducing the incidence and severity of these debilitating wounds. With proper care, most decubitus ulcers can heal completely, though severe cases may require surgical intervention and can result in permanent disability or life-threatening complications.

Symptoms

Decubitus ulcer symptoms vary significantly depending on the stage of development, from early warning signs to advanced tissue damage requiring immediate medical intervention.

Primary Symptoms

Stage-Based Symptoms

Stage 1: Non-Blanchable Erythema

• Persistent red discoloration of intact skin
• Skin does not blanch (turn white) when pressed
• Area may be warmer or cooler than surrounding skin
• Possible pain, burning, or itching sensation
• In dark skin: may appear as purple, blue, or darker area
• Skin remains intact without open wounds
• Increased firmness or softness compared to adjacent tissue

Stage 2: Partial Thickness Skin Loss

• Shallow open ulcer with red or pink wound bed
• Loss of epidermis and possibly dermis
• May present as intact or ruptured blister
• Painful wound due to exposed nerve endings
• No slough or eschar present
• Wound margins may be irregular
• Surrounding skin may show inflammation

Stage 3: Full Thickness Skin Loss

• Deep crater-like wound
• Loss of skin through epidermis and dermis
• Subcutaneous fat may be visible
• Possible presence of slough (yellow tissue)
• Undermining or tunneling may be present
• Bone, tendon, or muscle not visible
• Variable pain levels
• Risk of infection increases significantly

Stage 4: Full Thickness Tissue Loss

• Extensive tissue destruction
• Bone, tendon, or muscle exposed
• Slough or eschar may be present
• Often includes undermining and tunneling
• High risk of infection and sepsis
• May extend into joint spaces
• Severe pain or paradoxically less pain due to nerve damage
• Significant functional impairment

Associated Symptoms

Local Symptoms

• Pain ranging from mild to severe
• Burning or stinging sensations
• Itching around wound edges
• Swelling in surrounding tissues
• Warmth or heat at the site
• Drainage or exudate from wounds
• Foul odor (may indicate infection)
• Changes in skin color around the ulcer

Systemic Symptoms

• Fever (indicates possible infection)
• Fatigue and weakness
• Loss of appetite
• Sleep disturbances due to pain
• Anxiety or depression
• General malaise
• Weight loss
• Confusion (especially in elderly)

Infection-Related Symptoms

• Increased pain or new onset pain
• Purulent drainage (pus)
• Foul-smelling discharge
• Increased redness around wound
• Warmth extending beyond wound margins
• Red streaking from the wound
• Fever and chills
• Increased white blood cell count
• Delayed healing or wound enlargement
• Friable or easily bleeding tissue

Complications Symptoms

Cellulitis

• Spreading skin redness
• Skin that feels hot to touch
• Swelling beyond wound area
• Tender lymph nodes
• Red streaking toward lymph nodes

Osteomyelitis (Bone Infection)

• Deep, persistent pain
• Bone exposure in wound
• Probe-to-bone test positive
• Systemic symptoms of infection
• Poor response to wound treatment

Sepsis

• High fever or hypothermia
• Rapid heart rate
• Rapid breathing
• Confusion or altered mental status
• Low blood pressure
• Decreased urine output
• Cold, clammy skin

Location-Specific Symptoms

Common Pressure Points

• Sacrum and coccyx: Most common site
• Heels: Especially in bedridden patients
• Ischial tuberosities: Sitting pressure points
• Greater trochanter: Hip area in side-lying position
• Malleoli: Ankle bones
• Occiput: Back of head in supine patients
• Elbows and shoulders: Upper extremity pressure points

Non-Verbal Signs

In patients unable to communicate verbally:

• Restlessness or agitation
• Changes in eating or sleeping patterns
• Protective positioning
• Grimacing or facial expressions of pain
• Increased vocalization or moaning
• Withdrawal from touch
• Changes in vital signs
• Behavioral changes

Healing Process Symptoms

Positive Healing Signs

• Decreased wound size
• Healthy red granulation tissue
• Decreased pain levels
• Absence of infection signs
• Pink wound edges
• Minimal, clear drainage

Concerning Healing Signs

• Wound enlargement
• Increased pain
• Change in drainage color or odor
• Darkening wound bed
• New areas of breakdown
• Delayed epithelialization

Causes

Decubitus ulcers result from a combination of mechanical forces, tissue vulnerability, and time factors that compromise blood flow and tissue integrity.

Primary Mechanical Forces

Pressure

• Sustained pressure: Exceeding capillary perfusion pressure (32 mmHg)
• Duration: Continuous pressure for 2+ hours
• Body weight distribution: Concentration over bony prominences
• External pressure sources: Mattresses, chairs, medical devices
• Interface pressure: Between body and support surface
• Internal pressure: From swelling or positioning

Shear Forces

• Parallel forces causing tissue layers to slide
• Head of bed elevation >30 degrees
• Sliding down in bed or chair
• Improper lifting or repositioning
• Tissue stretching and blood vessel distortion
• Deep tissue injury mechanisms

Friction

• Surface rubbing against skin
• Dragging during repositioning
• Repetitive movement against surfaces
• Rough or abrading materials
• Removal of superficial skin layers
• Increased vulnerability to pressure

Tissue Vulnerability Factors

Circulatory Compromises

• Reduced blood flow and perfusion
• Atherosclerosis and vascular disease
• Diabetes-related microvascular disease
• Hypotension and shock states
• Cardiac failure and reduced output
• Anemia reducing oxygen delivery
• Smoking-related vasoconstriction

Cellular and Metabolic Factors

• Reduced cellular metabolism
• Impaired protein synthesis
• Decreased collagen production
• Altered inflammatory response
• Reduced tissue repair capacity
• Oxidative stress damage
• Cellular hypoxia and death

Contributing Medical Conditions

Neurological Conditions

• Spinal cord injuries: Loss of sensation and mobility
• Stroke: Paralysis and reduced awareness
• Peripheral neuropathy: Decreased sensation
• Multiple sclerosis: Progressive mobility loss
• Traumatic brain injury: Altered consciousness
• Dementia: Reduced awareness and self-care

Cardiovascular Conditions

• Congestive heart failure
• Peripheral vascular disease
• Hypotension and shock
• Atherosclerosis
• Venous insufficiency
• Cardiac arrhythmias

Metabolic and Endocrine Disorders

• Diabetes mellitus: Impaired healing and circulation
• Malnutrition: Protein and vitamin deficiencies
• Obesity: Increased pressure and mobility issues
• Kidney disease: Fluid retention and toxin buildup
• Liver disease: Protein synthesis impairment
• Thyroid disorders: Metabolic dysfunction

Age-Related Factors

Skin Changes with Aging

• Thinning of epidermis and dermis
• Reduced subcutaneous fat padding
• Decreased skin elasticity
• Slower wound healing
• Reduced blood vessel density
• Impaired temperature regulation
• Decreased sebum production

Physiological Changes

• Reduced muscle mass and strength
• Decreased bone density
• Impaired immune function
• Slower metabolism
• Reduced protein synthesis
• Altered medication metabolism

Environmental and Iatrogenic Causes

Healthcare-Related Factors

• Inadequate repositioning protocols
• Inappropriate support surfaces
• Medical device-related pressure
• Restraint use
• Prolonged surgical procedures
• ICU positioning and sedation
• Insufficient nursing care

Equipment-Related Causes

• Hard or inappropriate mattresses
• Poorly fitting medical devices
• Oxygen masks and tubing
• Urinary catheters
• Compression devices
• Wheelchairs and seating
• Casts and braces

Moisture-Related Causes

• Incontinence: Urine and fecal contamination
• Excessive sweating: Maceration of skin
• Wound drainage: Contaminating adjacent skin
• Poor hygiene: Accumulated moisture and bacteria
• Improper cleansing: Harsh chemicals or techniques

Nutritional Deficiency Causes

Protein Deficiency

• Inadequate protein intake
• Negative nitrogen balance
• Hypoalbuminemia
• Impaired collagen synthesis
• Reduced immune function
• Poor wound healing capacity

Micronutrient Deficiencies

• Vitamin C: Collagen synthesis impairment
• Vitamin A: Epithelialization problems
• Zinc: Wound healing delays
• Iron: Anemia and oxygen delivery
• B vitamins: Cellular metabolism

Medication-Related Causes

• Corticosteroids: Impaired healing and immune function
• Chemotherapy: Reduced cell division and repair
• Immunosuppressants: Decreased healing capacity
• Anticoagulants: Increased bleeding risk
• Sedatives: Reduced movement and awareness
• Vasoactive drugs: Altered circulation

Psychological and Social Causes

• Depression affecting self-care
• Cognitive impairment
• Social isolation
• Lack of caregiver support
• Financial barriers to care
• Poor health literacy
• Substance abuse

Risk Factors

Multiple factors can increase the likelihood of developing decubitus ulcers, with immobility being the most significant risk factor.

Immobility and Activity Limitations

Complete Immobility

• Spinal cord injuries
• Coma or vegetative state
• Severe sedation
• Paralysis from stroke
• Mechanical ventilation
• Post-surgical restrictions
• Severe weakness or fatigue

Limited Mobility

• Wheelchair dependence
• Prolonged bed rest
• Joint contractures
• Severe arthritis
• Muscle weakness
• Balance problems
• Pain limiting movement

Age-Related Risk Factors

Advanced Age (>65 years)

• Thinner, more fragile skin
• Reduced subcutaneous fat
• Slower healing processes
• Multiple comorbidities
• Medication interactions
• Reduced mobility
• Sensory impairments

Pediatric Considerations

• Premature infants
• Congenital conditions
• Prolonged hospitalization
• Medical device use
• Neurological impairments

Medical Risk Factors

Cardiovascular Conditions

• Heart failure
• Peripheral vascular disease
• Hypotension
• Shock states
• Atherosclerosis
• Anemia
• Blood clotting disorders

Neurological Conditions

• Spinal cord injury
• Stroke
• Multiple sclerosis
• Parkinson's disease
• Peripheral neuropathy
• Dementia
• Traumatic brain injury

Metabolic and Endocrine Conditions

• Diabetes mellitus
• Malnutrition
• Kidney disease
• Liver disease
• Thyroid disorders
• Adrenal insufficiency

Skin and Tissue Risk Factors

Skin Conditions

• Dry, cracked skin
• Previous pressure ulcers
• Edema and swelling
• Skin infections
• Radiation-damaged skin
• Surgical incisions
• Skin allergies

Body Composition

• Very low body weight
• Obesity
• Muscle wasting
• Bony prominences
• Loss of subcutaneous fat
• Dehydration

Sensory and Cognitive Risk Factors

Sensory Impairments

• Loss of pain sensation
• Reduced pressure awareness
• Diabetic neuropathy
• Spinal cord lesions
• Peripheral nerve damage
• Medication-induced numbness

Cognitive Impairments

• Dementia
• Delirium
• Mental illness
• Developmental disabilities
• Sedation effects
• Altered consciousness

Healthcare Setting Risk Factors

ICU and Hospital Factors

• Prolonged ICU stay
• Mechanical ventilation
• Vasopressor use
• Multiple procedures
• Sedation protocols
• Understaffing
• Frequent repositioning delays

Long-term Care Factors

• Nursing home residence
• Limited mobility programs
• Inadequate staffing ratios
• Poor nutritional programs
• Lack of specialized equipment
• Insufficient assessment protocols

Medication Risk Factors

High-Risk Medications

• Corticosteroids
• Immunosuppressants
• Chemotherapy agents
• Anticoagulants
• Sedatives and opioids
• Vasoactive medications
• Anti-inflammatory drugs

Nutritional Risk Factors

Malnutrition Indicators

• Albumin <3.5 g/dL
• Prealbumin <15 mg/dL
• Unintentional weight loss >5%
• BMI <18.5 kg/m²
• Poor oral intake
• Swallowing difficulties
• Gastrointestinal disorders

Environmental Risk Factors

• Inappropriate support surfaces
• Hard or worn mattresses
• Inadequate cushioning
• Medical device pressure
• Restraint use
• Poor positioning aids
• Excessive heat or moisture

Psychosocial Risk Factors

• Depression
• Social isolation
• Lack of family support
• Financial constraints
• Poor health literacy
• Substance abuse
• Non-compliance with care

Risk Assessment Tools

Braden Scale

• Sensory perception
• Moisture
• Activity level
• Mobility
• Nutrition
• Friction and shear

Norton Scale

• Physical condition
• Mental condition
• Activity
• Mobility
• Incontinence

High-Risk Populations

• Spinal cord injury patients
• ICU patients
• Elderly nursing home residents
• Surgical patients (long procedures)
• Patients with multiple comorbidities
• End-of-life care patients
• Patients with cognitive impairment

Diagnosis

Diagnosis of decubitus ulcers relies primarily on clinical assessment, staging, and evaluation of contributing factors and complications.

Clinical Assessment

Visual Inspection

• Complete skin assessment
• Identification of all pressure points
• Documentation of wound characteristics
• Photography for monitoring
• Assessment under proper lighting
• Use of magnification if needed
• Systematic head-to-toe examination

Physical Examination

• Palpation: Temperature, firmness, blanching
• Measurement: Length, width, depth
• Probing: Tunneling and undermining
• Surrounding tissue: Erythema, induration
• Drainage assessment: Amount, color, odor
• Pain evaluation: Location, severity, character

Staging System

Stage 1: Non-Blanchable Erythema

• Intact skin with persistent, non-blanchable redness
• Area may be painful, firm, soft, warmer, or cooler
• In dark skin: may not have visible blanching
• May appear as defined area of discoloration
• Indicates "at risk" persons

Stage 2: Partial Thickness Skin Loss

• Loss of dermis presenting as shallow open ulcer
• Red or pink wound bed without slough
• May present as intact or open/ruptured blister
• Shiny or dry shallow ulcer
• No bruising (indicates deep tissue injury)

Stage 3: Full Thickness Skin Loss

• Loss of skin through full thickness
• Subcutaneous fat may be visible
• Slough may be present
• May include undermining and tunneling
• Depth varies by anatomical location
• Bone/tendon/muscle are NOT visible

Stage 4: Full Thickness Tissue Loss

• Full thickness tissue loss
• Exposed bone, tendon, or muscle
• Slough or eschar may be present
• Often includes undermining and tunneling
• Depth varies by anatomical location
• Can extend into muscle and supporting structures

Special Categories

Unstageable: Obscured Full Thickness

• Full thickness tissue loss
• Wound bed covered by slough and/or eschar
• True depth cannot be determined
• Stable eschar on heels should not be removed
• Requires debridement for accurate staging

Deep Tissue Injury (DTI)

• Purple or maroon localized area
• Discolored skin or blood-filled blister
• Result of damage to underlying soft tissue
• May be difficult to detect in dark skin
• Area may be painful, firm, mushy, boggy
• May evolve rapidly

Wound Assessment Parameters

Dimensional Measurements

• Length: Head to toe measurement
• Width: Side to side measurement
• Depth: Deepest point measurement
• Undermining: Tissue destruction under skin edges
• Tunneling: Narrow passageway under wound surface

Wound Bed Assessment

• Granulation tissue: Red, healthy, bumpy
• Slough: Yellow, stringy, wet tissue
• Eschar: Black, leathery, dry tissue
• Epithelial tissue: Pink, smooth, new skin
• Exposed structures: Bone, tendon, muscle

Exudate Characteristics

• Amount: None, scant, moderate, heavy
• Color: Clear, yellow, green, brown, bloody
• Consistency: Thin, thick, purulent
• Odor: None, mild, strong, foul

Diagnostic Testing

Laboratory Tests

• Nutritional markers: Albumin, prealbumin, transferrin
• Inflammatory markers: WBC, ESR, CRP
• Metabolic panel: Glucose, electrolytes
• Hemoglobin/hematocrit: Assess anemia
• Wound culture: If infection suspected

Microbiological Studies

• Quantitative tissue biopsy: Gold standard
• Swab cultures: Less reliable but commonly used
• Blood cultures: If systemic infection suspected
• Bone biopsy: If osteomyelitis suspected

Imaging Studies

When Imaging is Indicated

• Suspected osteomyelitis
• Deep tissue involvement
• Presence of foreign bodies
• Surgical planning
• Assessment of healing progress

Imaging Modalities

• X-rays: Detect bone changes, foreign objects
• MRI: Soft tissue detail, osteomyelitis
• CT scan: Bone and soft tissue assessment
• Ultrasound: Tissue layers, fluid collections
• Bone scan: Detect bone infection

Risk Assessment Tools

Braden Scale Assessment

• Score range: 6-23
• Lower scores indicate higher risk
• Risk levels: High (≤12), Moderate (13-14), Mild (15-18)
• Should be performed on admission and regularly

Norton Scale Assessment

• Score range: 5-20
• Risk levels: High (≤11), Medium (12-14), Low (≥15)
• Simple and quick to use
• Good for long-term care settings

Differential Diagnosis

• Venous ulcers: Lower extremity, venous insufficiency
• Arterial ulcers: Distal extremities, poor perfusion
• Diabetic ulcers: Feet, neuropathy-related
• Surgical wounds: Incision-related breakdown
• Skin cancer: Non-healing lesions
• Traumatic wounds: Injury-related
• Burn injuries: Heat, chemical, or radiation

Documentation Requirements

• Complete wound assessment
• Staging and measurements
• Risk factor assessment
• Photography (with consent)
• Treatment plan
• Progress monitoring
• Complications noted

Quality Measures

• Pressure ulcer prevalence rates
• Hospital-acquired pressure ulcer rates
• Healing rates and timeframes
• Prevention protocol compliance
• Cost-effectiveness measures
• Patient satisfaction scores

Treatment Options

Treatment of decubitus ulcers requires a comprehensive, multidisciplinary approach focusing on wound care, pressure relief, and addressing underlying factors.

Pressure Relief and Repositioning

Repositioning Protocols

• Frequency: Every 2 hours for bed-bound patients
• Chair repositioning: Every 15 minutes if able, hourly if not
• 30-degree lateral position: Avoid direct pressure on trochanters
• Heel elevation: Keep heels off bed surface
• Head of bed: Keep ≤30 degrees when possible
• Use of pillows: Support and positioning aids

Support Surface Selection

• Static air mattresses: Basic pressure redistribution
• Alternating pressure mattresses: Dynamic pressure relief
• Low air loss beds: Moisture and temperature control
• Air fluidized beds: Maximum pressure redistribution
• Foam overlays: Basic cushioning
• Gel pads: Targeted pressure relief

Wound Care Management

Wound Cleansing

• Normal saline: Preferred cleaning solution
• Gentle irrigation: 4-15 psi pressure
• Avoid harsh chemicals: Hydrogen peroxide, betadine
• Warm solutions: Promote comfort and healing
• Minimal mechanical force: Prevent tissue damage

Debridement Options

• Sharp debridement: Surgical removal of necrotic tissue
• Enzymatic debridement: Topical enzyme applications
• Autolytic debridement: Body's natural process
• Mechanical debridement: Wet-to-dry dressings
• Biological debridement: Medical maggots (rare)

Dressing Selection

Stage 1 Ulcers

• Transparent films
• Hydrocolloid dressings
• Protective barriers
• Skin sealants

Stage 2 Ulcers

• Hydrocolloid dressings
• Transparent films
• Hydrogel sheets
• Foam dressings

Stage 3 and 4 Ulcers

• Hydrogel amorphous
• Calcium alginate
• Foam dressings
• Hydrofiber dressings
• Negative pressure wound therapy

Advanced Wound Therapies

Negative Pressure Wound Therapy (NPWT)

• Promotes granulation tissue formation
• Reduces edema and bacterial load
• Increases blood flow
• Suitable for Stage 3 and 4 ulcers
• Requires adequate blood supply
• Regular dressing changes needed

Growth Factors and Biologics

• Platelet-derived growth factor
• Recombinant human growth factors
• Platelet-rich plasma
• Bioengineered skin substitutes
• Collagen matrices

Hyperbaric Oxygen Therapy

• Enhances tissue oxygenation
• Promotes angiogenesis
• Reduces infection risk
• Reserved for refractory cases
• Requires specialized facilities

Surgical Management

Indications for Surgery

• Large Stage 3 or 4 ulcers
• Non-healing despite optimal care
• Osteomyelitis present
• Significant undermining
• Patient appropriate for surgery
• Adequate perfusion present

Surgical Procedures

• Surgical debridement: Removal of necrotic tissue
• Primary closure: Direct wound closure
• Skin grafts: Split or full thickness
• Flap reconstruction: Muscle or fasciocutaneous
• Bone removal: Osteomyelitis or prominent bones

Infection Management

Topical Antimicrobials

• Silver-containing dressings
• Iodine-based preparations
• Medical honey
• Antimicrobial foams
• Chlorhexidine solutions

Systemic Antibiotics

• Indications: Cellulitis, osteomyelitis, sepsis
• Culture-guided therapy: Based on sensitivities
• Empirical therapy: Broad-spectrum initially
• Duration: 7-14 days for soft tissue, 4-6 weeks for bone

Nutritional Support

Protein Requirements

• 1.2-1.5 g/kg/day for healing
• Up to 2.0 g/kg/day for severe ulcers
• High-quality protein sources
• Supplement if inadequate intake
• Monitor albumin and prealbumin

Micronutrient Support

• Vitamin C: 500-1000 mg daily
• Vitamin A: 10,000-25,000 IU daily
• Zinc: 15-20 mg daily
• Vitamin E: Antioxidant support
• B vitamins: Cellular metabolism

Pain Management

Assessment and Monitoring

• Regular pain assessments
• Use of pain scales
• Identify pain triggers
• Monitor for signs in non-verbal patients
• Document response to interventions

Pharmacological Management

• Topical anesthetics: For dressing changes
• Oral analgesics: Acetaminophen, NSAIDs
• Opioids: For severe pain, short-term use
• Anticonvulsants: For neuropathic pain
• Antidepressants: Chronic pain management

Non-Pharmacological Approaches

• Positioning for comfort
• Distraction techniques
• Relaxation methods
• Heat and cold therapy
• Music and aromatherapy
• Massage (around wound)

Monitoring and Evaluation

Healing Assessment

• Weekly measurements
• Photography documentation
• Tissue quality evaluation
• Exudate monitoring
• Pain level changes
• Infection surveillance

Treatment Adjustment

• Dressing modification based on wound status
• Frequency adjustments
• Addition of advanced therapies
• Nutritional plan updates
• Support surface changes
• Specialist consultations

Multidisciplinary Care Team

• Wound care specialist: Advanced wound management
• Plastic surgeon: Surgical interventions
• Dietitian: Nutritional optimization
• Physical therapist: Mobility and positioning
• Occupational therapist: Adaptive equipment
• Social worker: Discharge planning and resources
• Nursing staff: Daily care and monitoring

Prevention

Prevention of decubitus ulcers is far more effective and cost-efficient than treatment, requiring systematic approaches to risk assessment and intervention.

Risk Assessment and Screening

Regular Risk Assessment

• Braden Scale assessment on admission
• Daily reassessment for high-risk patients
• Weekly assessment for stable patients
• Assessment with any condition changes
• Documentation of risk scores
• Communication of risk levels to care team

Skin Inspection Protocols

• Daily head-to-toe assessment: For all at-risk patients
• Focus on pressure points: Sacrum, heels, hips, elbows
• Document findings: Any skin changes or concerns
• Use proper lighting: Ensure adequate visualization
• Involve patients/families: In inspection when appropriate

Pressure Redistribution

Repositioning Strategies

• Turn schedule: Every 2 hours minimum
• 30-degree lateral position: Avoid direct pressure on bony prominences
• Pillow bridging: Support between pressure points
• Heel elevation: Completely off bed surface
• Chair repositioning: Every 15 minutes if able
• Document position changes: Maintain turning logs

Support Surface Selection

• Risk-appropriate surfaces: Match to patient risk level
• Static surfaces: For low to moderate risk
• Dynamic surfaces: For high risk or existing ulcers
• Specialty beds: For complex cases
• Chair cushions: Pressure redistribution for seating
• Regular evaluation: Effectiveness and condition

Skin Care and Hygiene

Skin Care Protocols

• Gentle cleansing: pH-balanced, mild soap
• Moisturization: Daily application of emollients
• Barrier protection: For incontinence-associated dermatitis
• Avoid massage: Over bony prominences
• Temperature considerations: Lukewarm water for bathing
• Pat dry technique: Avoid vigorous rubbing

Incontinence Management

• Prompt cleaning after soiling
• Use of protective barriers
• Appropriate absorbent products
• Toileting schedules
• Treatment of underlying causes
• Skin assessment with each change

Nutrition and Hydration

Nutritional Assessment

• Comprehensive nutritional screening
• Laboratory markers monitoring
• Caloric needs calculation
• Protein requirements assessment
• Micronutrient evaluation
• Swallowing assessment if needed

Nutritional Interventions

• Adequate calories: 30-35 kcal/kg/day
• Protein intake: 1.2-1.5 g/kg/day
• Hydration: 1500-2000 mL daily unless contraindicated
• Supplements: As indicated by deficiencies
• Feeding assistance: For dependent patients
• Alternative nutrition: Enteral or parenteral if needed

Mobility and Activity

Mobility Promotion

• Early mobilization protocols
• Progressive activity programs
• Range of motion exercises
• Transfer training
• Assistive device provision
• Fall prevention measures

Physical Therapy Integration

• Assessment of mobility limitations
• Individualized exercise programs
• Positioning education
• Equipment recommendations
• Family/caregiver training
• Progress monitoring

Medical Device Management

Device-Related Pressure Prevention

• Regular device assessment
• Proper sizing and fit
• Padding and protective barriers
• Rotation of sites when possible
• Removal when no longer needed
• Skin inspection under devices

Common Device Considerations

• Oxygen masks: Bridge design, padding
• Urinary catheters: Secure without tension
• Compression devices: Proper pressure settings
• Restraints: Minimal use, frequent checks
• Prosthetics: Regular fit assessment

Environmental Modifications

Room Environment

• Temperature control
• Humidity management
• Bedding selection
• Lighting adequacy
• Accessibility features
• Safety equipment

Equipment and Supplies

• Pressure-redistribution surfaces
• Positioning aids and pillows
• Skin care products
• Protective barriers
• Monitoring tools
• Educational materials

Education and Training

Staff Education

• Pressure ulcer pathophysiology
• Risk assessment tools
• Prevention strategies
• Proper positioning techniques
• Skin care protocols
• Documentation requirements

Patient and Family Education

• Risk factors explanation
• Prevention importance
• Self-inspection techniques
• Positioning and movement
• Nutrition and hydration
• When to seek help

Quality Improvement

Monitoring and Metrics

• Pressure ulcer incidence rates
• Hospital-acquired pressure ulcer rates
• Prevention protocol compliance
• Risk assessment completion
• Repositioning adherence
• Cost-effectiveness measures

Continuous Improvement

• Regular protocol review
• Staff feedback incorporation
• Best practice updates
• Technology integration
• Benchmarking with other facilities
• Research participation

Special Populations

ICU Patients

• Enhanced monitoring protocols
• Specialty bed consideration
• Sedation weaning for movement
• Vasopressor impact awareness
• Family involvement when possible

Surgical Patients

• Preoperative risk assessment
• Intraoperative pressure redistribution
• Postoperative positioning protocols
• Early mobilization planning
• Pain management for movement

Long-term Care Residents

• Comprehensive care planning
• Family education and involvement
• Activity programming
• Nutritional monitoring
• Regular reassessment

When to See a Doctor

Early recognition and prompt medical intervention are crucial for preventing progression and complications of decubitus ulcers.

Seek Immediate Emergency Care

• Signs of systemic infection or sepsis
• High fever (>101.5°F/38.6°C)
• Rapid heart rate or low blood pressure
• Confusion or altered mental status
• Excessive bleeding from wound
• Severe pain that cannot be controlled
• Signs of shock (cold, clammy skin)
• Difficulty breathing

Contact Healthcare Provider Urgently

• New skin breakdown or worsening of existing ulcer
• Signs of wound infection (redness, warmth, pus)
• Foul odor from wound
• Red streaking from wound site
• Fever with wound present
• Wound not healing after 2-4 weeks
• Sudden increase in wound size
• Exposure of bone, tendon, or muscle

Schedule Regular Medical Evaluation

• Any Stage 1 pressure ulcer (persistent redness)
• High-risk patients needing assessment
• Routine wound care and monitoring
• Medication review for at-risk patients
• Nutritional assessment needs
• Equipment and supply prescriptions
• Care plan updates
• Prevention strategy development

High-Risk Patients Requiring Monitoring

Immediate Medical Attention Needed

• Spinal cord injury patients
• Patients with diabetes
• Immunocompromised individuals
• Elderly patients with limited mobility
• Patients on prolonged bed rest
• Those with previous pressure ulcers
• Patients with poor nutrition
• ICU patients on life support

Home Care Scenarios

When to Call Healthcare Provider

• Caregiver unable to manage wound care
• Questions about dressing changes
• Equipment malfunction or needs
• Changes in patient condition
• Pain management concerns
• Nutrition or hydration issues
• Need for additional resources
• Family concerns about care

Emergency Situations at Home

• Patient becomes unresponsive
• Severe bleeding cannot be controlled
• Signs of sepsis develop
• Severe pain unrelieved by medications
• Sudden onset of breathing difficulties
• Loss of consciousness
• Chest pain or heart palpitations

Specialist Referrals

Wound Care Specialist

• Stage 3 or 4 pressure ulcers
• Non-healing wounds after 4 weeks
• Complex wound management needs
• Advanced dressing requirements
• Need for specialized equipment
• Multiple pressure ulcers

Plastic Surgeon

• Large Stage 4 ulcers
• Surgical intervention consideration
• Flap reconstruction needs
• Failed conservative management
• Osteomyelitis requiring bone removal

Other Specialists

• Infectious disease: Complicated infections
• Endocrinologist: Diabetes management
• Nutritionist: Malnutrition concerns
• Physical therapist: Mobility issues
• Social worker: Home care resources

Monitoring During Treatment

Signs of Healing Progress

• Decreasing wound size
• Healthy red tissue growth
• Decreased pain levels
• Clean wound appearance
• Reduced drainage
• Pink wound edges

Concerning Changes During Treatment

• Wound enlargement
• Increased pain
• Change in drainage color or odor
• Development of fever
• Surrounding skin changes
• Patient condition deterioration

Preparation for Medical Visits

Information to Gather

• Complete medical history
• Current medications and supplements
• Wound progression timeline
• Pain levels and patterns
• Current care routine
• Functional status changes
• Nutrition and hydration status

Questions to Ask Healthcare Provider

• What stage is the pressure ulcer?
• What treatment options are available?
• How long will healing take?
• What can be done to prevent recurrence?
• What signs should prompt immediate call?
• What equipment or supplies are needed?
• How often should follow-up occur?
• What resources are available for home care?

Follow-up Care Schedule

Regular Monitoring

• Weekly: For healing ulcers
• Bi-weekly: For stable conditions
• Monthly: For prevention monitoring
• As needed: For any concerns
• Emergency: For complications

Long-term Management

• Risk reassessment
• Prevention strategy updates
• Equipment maintenance
• Education reinforcement
• Quality of life assessment
• Care plan modifications

Related Conditions

References