II. Epidemiology

  1. Incidence: 17-35% in Nursing Home residents
  2. Prevalence: 3 Million affected in U.S.
  3. Estimated to cost $11 Billion per year in U.S.

III. Pathophysiology

  1. External localized pressure exceeds capillary blood flow to affected region
  2. Results in local tissue ischemia and injury

IV. Risk Factors

  1. Key risk factors
    1. Non-ambulatory patients
    2. Decreased perfusion
    3. Local tissue edema
    4. Pre-existing Stage 1 Pressure Sore
  2. Other risk factors
    1. Underweight, malnourished or Cachexia
    2. Cognitive Impairment or Dementia
    3. Incontinence (and other causes of excessive moisture)
    4. Advanced age

V. Signs: Distribution (bony prominences)

  1. Common
    1. Heel
    2. Sacrum
    3. Ischial tuberosity
    4. Buttock
  2. Other
    1. Ear
    2. Occiput
    3. Shoulder
    4. Scapula
    5. Elbow
    6. Pelvis
    7. Greater Trochanter
    8. Lateral Malleolus

VI. Examination: Ulcer Characterization

  1. Basic description
    1. Location
    2. Size (Length x Width x Depth)
  2. Grade (Types 1-4)
    1. See Decubitus Ulcer Grade
    2. Grade 1: Nonblanchable erythema of intact skin
    3. Grade 2: Superficial or partial thickness skin loss
    4. Grade 3: Full thickness skin loss with subcutaneous damage (crater to fascia)
    5. Grade 4: Full thickness skin loss with extensive deep damage to muscle, bone, tendon
  3. Additional findings
    1. Sinus tracts
    2. Exudate
    3. Necrotic tissue
    4. Granulation tissue
    5. Discharge and signs of infection

VII. Labs

  1. Wound culture
    1. Typically not indicated except to identify MRSA
    2. Levine Technique is preferred
      1. Rotate culture swab over a 1 cm patch of wound
      2. Apply enough pressure for fluid to collect in wound site for 5 seconds
      3. Reddy (2012) JAMA 307(6): 605-11 [PubMed]

VIII. Differential Diagnosis

  1. See Leg Ulcer Causes
  2. Stasis ulcer
    1. Venous Insufficiency
    2. Lymphedema
  3. Ischemic ulcer (Peripheral Vascular Disease)
  4. Vasculitic ulcer

IX. Management: General Approach

  1. Weekly clinical assessment
  2. Daily observation by caregiver
  3. Key point: Minimize moisture, friction and sheering
    1. Without this, no Pressure Sore will heal
    2. Consider modified beds or bed overlays (see Pressure Sore Positioning)
  4. Patient positioning
    1. See Pressure Sore Positioning
    2. Remove all pressure at the ulcer site
    3. Frequent repositioning (every 2 hours)
  5. Wound cleaning and debridement
    1. See Decubitus Ulcer Cleansing
    2. See Decubitus Ulcer Debridement
    3. Avoid removing a dry, non-inflamed, non-fluctuant intact eschar at heel
      1. Provides intact barrier to further injury

X. Management: Wound Dressing

  1. See Wound Dressing for complete list and selection criteria
  2. Precautions
    1. Dressings should promote moist Wound Healing (without being wet)
    2. Avoid Wet-to-Dry Dressings
      1. May slow healing and results in pain on removal
      2. Wet-to-Moist Dressing however may be used (see below)
  3. Decubitus Ulcer Grade 1 (red but intact skin)
    1. No dressing is typically needed
    2. Transparent Film Dressing (e.g. Tegaderm)
  4. Decubitus Ulcer Grade 2-4
    1. Shallow - Dry wounds
      1. Thin Hydrocolloid Dressing (e.g. Tegaderm Thin, Primacol Thin, Restore Extra Thin)
      2. Hydrogels (provide moisture to dry wounds)
      3. Transparent Film Dressing (e.g. Tegaderm)
      4. Wet-to-Moist Dressing
      5. Cover with nonadherent gauze wrap
    2. Shallow - Wet wounds
      1. Hydrocolloid Dressing (e.g. Duoderm CGF) with or without absorbent paste or powder
      2. Cover with nonadherent gauze wrap
    3. Shallow - Very Wet wounds
      1. Foam Dressing (e.g. Allevyn) - preferred
      2. Alginate Dressing
      3. Cover with nonadherent gauze wrap
    4. Deep - Dry wounds
      1. Fill wound with damp gauze or Hydrogel Dressing
      2. Cover with Hydrocolloid Dressing
      3. Cover with Transparent Film Dressing (e.g. Tegaderm) or nonadherent gauze wrap
    5. Deep - Wet wounds
      1. Foam Dressing (e.g. Allevyn)
      2. Consider filling with Alginate Dressing
      3. Cover with Transparent Film Dressing (e.g. Tegaderm)

XI. Management: Nutrition

  1. See Nutrition in Wound Healing
  2. Correct malnutrition and specific deficiencies

XII. Management: Control source of pain

  1. Cover wounds
  2. Adjust support surfaces
  3. Reposition patient frequently
  4. Provide analgesia with dressing changes and debridement
  5. Control moisture
    1. Contributes to maceration and skin breakdown
    2. Airflow surface may help keep area dry
    3. Do not use Incontinence briefs (impedes airflow)

XIII. Management: Adjunctive Therapy

  1. Electrotherapy (Electrical stimulation)
    1. Direct electric, pulse current via electrodes applied to wound bed for 1 hour daily
    2. Indicated in Grade 3-4 Pressure Ulcers refractory to other care
    3. Contraindicated in cancer and Osteomyelitis
    4. Kawasaki (2014) Wound Repair Regen 22(2): 161-73 [PubMed]
  2. Insufficient evidence to support use of other adjuncts
    1. Topical and systemic agents
    2. Hyperbaric treatment
    3. Infared or ultraviolet light exposure

XIV. Course

  1. Anticipate Wound Healing over 2 to 4 weeks

XV. Complications

  1. Osteomyelitis
    1. Suspect if non-healing ulcer after 2 to 4 weeks
    2. Presume Osteomyelitis when bone is exposed within wound site
    3. Start with plain film, but typically requires bone scan or MRI
    4. Consult infectious disease
  2. Cellulitis (Bacterial superinfection) or Sepsis
    1. Stage 2 and greater Pressure Ulcers are colonized with Bacteria
    2. Adequate cleansing and debridement prevents infection
    3. Size and depth of ulcer does not distinguish need for antibiotics
    4. Risk factors for infection
      1. Foreign bodies within ulcer
      2. Large or necrotic ulcers
      3. Repeatedly contaminated sites (e.g. stool at Sacrum)
      4. Diabetes Mellitus or immunosuppression
      5. Diminished perfusion
    5. Findings suggestive of infection
      1. Increasing pain is a a key indicator of Wound Infection
      2. Fever
      3. Leukocytosis
      4. Increased purulent or foul discharge
      5. New necrotic tissue
      6. Surrounding erythema
      7. Irregular or friable granulation tissue
    6. Wound culture is typically not indicated
      1. Consider if determining presence of MRSA
      2. See Levine culture technique described above

XVII. References

  1. (2015) Presc Lett 22(5): 29
  2. Habif (1996) Clinical Derm, Mosby, p. 810-13
  3. PUGP (1994) Pressure Ulcer Treatment, AHCPR 95-0653
  4. PUGP (1995) Am Fam Physician 51(5):1207-22
  5. Krasner (1995) Prevention Management Pressure Ulcers
  6. Lewis (1996) Med-Surg Nursing, Mosby, p. 199-200
  7. Lueckenotte (1996) Gerontologic Nurs., Mosby, p. 800-7
  8. Way (1991) Current Surgical, Lange, p.95-108
  9. Bello (2000) JAMA 283(6): 716-8 [PubMed]
  10. Degreef (1998) Dermatol Clin 16(2): 365-75 [PubMed]
  11. Findlay (1996) Am Fam Physician 54(5): 1519-28 [PubMed]
  12. Knapp (1999) Pediatr Clin North Am 46(6):1201-13 [PubMed]
  13. Raetz (2015) Am Fam Physician 92(10): 888-94 [PubMed]
  14. Stotts (1997) Clin Geriatr Med 13(3): 565-73 [PubMed]
  15. Qaseem (2015) Ann Intern Med 162:359-9 [PubMed]

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Ontology: Pressure Ulcer (C0011127)

Definition (MSH) An ulceration caused by prolonged pressure on the SKIN and TISSUES when one stays in one position for a long period of time, such as lying in bed. The bony areas of the body are the most frequently affected sites which become ischemic (ISCHEMIA) under sustained and constant pressure.
Definition (MEDLINEPLUS)

Pressure sores are areas of damaged skin caused by staying in one position for too long. They commonly form where your bones are close to your skin, such as your ankles, back, elbows, heels and hips. You are at risk if you are bedridden, use a wheelchair, or are unable to change your position. Pressure sores can cause serious infections, some of which are life-threatening. They can be a problem for people in nursing homes.

You can prevent the sores by

  • Keeping skin clean and dry
  • Changing position every two hours
  • Using pillows and products that relieve pressure

Pressure sores have a variety of treatments. Advanced sores are slow to heal, so early treatment is best.

Definition (NCI) Death of tissue due to external pressure.
Definition (NCI_FDA) Death of tissue due to external pressure.
Definition (CSP) ulceration caused by prolonged pressure in patients permitted to lie too still for a long period of time; bony prominences of the body are the most frequently affected sites; ulcer is caused by ischemia of the underlying structures of the skin, fat, and muscles as a result of the sustained and constant pressure.
Concepts Disease or Syndrome (T047)
MSH D003668
ICD9 707.0, 707.00
ICD10 L89 , L89.9
SnomedCT 201248003, 28103007, 156424003, 90144002, 142668003, 165258002, 400192002, 399912005, 418172001, 420226006
LNC LP96870-8, MTHU021397, LA19028-2
English Bed sore, Bed Sores, Bedsore, Pressure Sore, Pressure Ulcers, Sore, Bed, Sores, Bed, Sores, Pressure, Ulcers, Decubitus, Ulcers, Pressure, Bed Sore, Decubitus ulcer, Sore, Pressure, Ulcer, Decubitus, Ulcer, Pressure, Decubitus pressure sore, Pressure sore(s), Pressure Sore Or Ulcer, Skin Decubitus Ulcer(s), decubitus ulcer, Pressure Ulcer, Pressure ulcer, site NOS, bed sore, Pressure ulcer of unspecified site, Pressure Ulcer [Disease/Finding], Pressure ulcers, contact ulcers, Ulcer;decubitus, Pressure;sore, pressure ulcers, bed sores, contact ulcer, decubitus skin ulcers, pressure sores, decubitus ulcers, Pressure ulcer, unspecified site, Decubitus ulcer, unspecified site, Pressure ulcer (diagnosis), chronic decubitus ulcer, Bed sores, Pressure Sores, Decubitus ulcers, Bedsores, Decubitus Ulcers, Decubitus ulcer (finding), Decubitus ulcer (disorder), Decubitus (pressure) ulcer, Decubitus ulcer (specify), Pressure sore, Decubitus ulcer (morphologic abnormality), Pressure ulcer (disorder), Pressure sore (disorder), PRESSURE, NECROSIS, NECROSIS, PRESSURE, PRESSURE SORES/ULCERS, SORES/ULCERS, PRESSURE, Decubitus, Decubiti, ULCERS/SORES, PRESSURE, Contact ulcer, decubitus, bedsore, decubitus; ulcer, pressure sore; sore, pressure ulcer; ulcer, pressure; sore, pressure; ulcer, skin; ulcer, decubitus, sore; pressure sore, sore; pressure, ulcer; decubitus, ulcer; pressure ulcer, ulcer; pressure, ulcer; skin, decubitus, pressure ulcer, Decubitus Ulcer, pressure sore, Pressure ulcer, Pressure ulcer (morphologic abnormality)
Spanish úlcera por presión, úlcera por presión (anomalía morfológica), úlcera de decúbito, úlcera de decúbito (anomalía morfológica), Úlcera por presión durante el decúbito, úlcera por decúbito (hallazgo), escara, úlcera de presión, decúbito, úlcera por decúbito (específica), úlcera de contacto, úlcera por presión (trastorno), úlcera por decúbito (anomalía morfológica), úlcera por decúbito (trastorno), úlcera por decúbito, Úlcera de decúbito, Escara, Llaga por Presión, Úlcera por Decúbito, Úlcera por Presión
Italian Ulcerazione da decubito, Piaga da letto, Ulcera da pressione, Decubitus ulcer, Piaghe da letto, Ulcera da decubito, Piaga da decubito
Dutch drukzweer, doorliggen, decubitus; ulcus, druk; ulcus, druk; zweer, drukulcus; ulcus, drukzweer; zweer, huid; ulcus, decubitus, ulcus; decubitus, ulcus; drukulcus, ulcus; druk, ulcus; huid, decubitus, zweer; drukzweer, zweer; druk, decubitus ulcus, Decubitus, Decubitusulcus, Doorliggen, Drukulcus
German Druckgeschwuer, Dekubitalgeschwuer, Dekubitus, Druckulkus, Wundliegen, Dekubitalgeschwür, Druckgeschwür
Portuguese Ferida de decúbito, Ferida de pressão, Úlcera por Pressão, Úlcera de Pressão, Úlceras de decúbito, Escara de Decúbito, Úlcera de Decúbito
Swedish Trycksår
Japanese ジョクソウセイカイヨウ, ジョクソウ, 褥瘡性潰瘍, 圧迫性潰瘍, じょく瘡性潰瘍, とこずれ潰瘍, 圧迫痛(褥創), 褥瘡, とこずれ, 床ずれ, 褥創, 褥創潰瘍, 褥瘡潰瘍
Czech otlakový vřed, dekubitus, proleženina, Proleženina, Proleženina z tlaku na podložku, Dekubitální vřed
Finnish Painehaava
Russian PROLEZHEN', ПРОЛЕЖЕНЬ
Korean 욕창성 및 압박부위 궤양
Croatian DEKUBITUS
Polish Odleżyna
Hungarian Felfekvéses fekély, Felfekvés, Decubitus fekély
Norwegian Trykksår, Liggesår, Dekubitalsår, Dekubitus
French Escarre, Ulcère de décubitus, Escarre de décubitus, Escarre de pression, Ulcère de pression