Decubitus Ulcer Wound Care, Prevention and Documentation

Decubitus Ulcer Wound CareAlso known as pressure ulcer, bed sore, or pressure sore, a decubitus ulcer forms where the pressure from the body’s weight presses the skin against a firm surface, such as a bed or wheelchair. The National Pressure Ulcer Advisory Panel (NPUAP) defines pressure ulcer as “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.” More common in bedridden patients, this may result in ischemia, cell death, and tissue necrosis. Though reduced mobility is still a major risk factor for pressure ulcer, patients who are ambulatory can also develop such ulcers.

Clear Documentation for Successful Monitoring

Ulcer wounds should be evaluated and accurately documented. Wound documentation must include physical characteristics such as location, category/stage, size, tissue type(s), wound bed and peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and epithelialization. Hospitals and clinics can choose to use a wound-specific EMR for documentation. With dedicated nurses’ and physicians’ module, customized wound EMR can help in effective documentation of every stage of the wound from the perspective of the nurse and the physician.

For the purposes of workup and treatment, documents should also include the stage of the pressure ulcer according to the system promulgated by the National Pressure Ulcer Advisory Panel (NPUAP). Stages are classified as-

  • Stage I: Non-blanchable redness of intact skin
  • Stage II: Partial thickness skin loss or blister
  • Stage III: Full thickness skin loss (fat visible)
  • Stage IV: Full thickness tissue loss (muscle/bone visible)

Extremely deep wound is unstageable. In some situations amputation may be necessary. After the initial assessment of the pressure ulcer, it is crucial to re-assess it at least weekly. This provides an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan.

Wound Care and Pain Management

Wound care may involve non-operative and operative methods. Deep wounds may require surgical removal or debridement of necrotic tissue. For stage I and II pressure ulcers, non-operative methods such as reduction of pressure, adequate debridement of necrotic and devitalized tissue, control of infection and meticulous wound care is recommended. Surgical intervention which includes flap reconstruction may be required for stage III and IV lesions. Wound management is done with cleansing agents, dressings, and antimicrobials.

Debridement pain can be reduced by using adequate pain control measures including additional dosing at times of wound manipulation, and wound cleansing, considering topical opioids (diamorphine or benzydamine 3%) and applying topical medications according to manufacturer’s directions. Chronic ulcer pain (neuropathic) is often managed with a local anesthetic or an adjuvant (antidepressant or antiepileptic), as well as with transcutaneous nerve stimulation, warm applications, or tricyclic antidepressants.

Prevention Tips

Patients with pressure ulcers are usually at risk for additional pressure ulcers; therefore, the prevention guidelines should also be followed for these individuals.

  • Particular attention should be given to bony areas where decubitus ulcers tend to develop
  • The person’s position should be changed every two hours
  • The skin should be kept clean and dry, moisturizing lotions can be used for fragile skin
  • Well-balanced, nutritious meals and 8-10 glasses of water daily is recommended
  • For wheelchair users, use cushions to relieve pressure

Help the person do daily range-of-motion exercising.