What are the management steps for a decubitus (pressure) ulcer?

Management of Decubitus Ulcers

The management of pressure ulcers requires a comprehensive approach that includes pressure relief, wound care, nutritional support, and consideration for surgical intervention when appropriate. 1, 2

Risk Assessment and Prevention

1. Risk Assessment

   • Use validated risk assessment tools such as Braden, Norton, or Waterlow scales to identify at-risk patients, although clinical judgment is equally effective 1
   • Regularly assess skin for early signs of pressure damage, especially over bony prominences

2. Pressure Relief Strategies

   • Use advanced static mattresses or overlays rather than standard hospital mattresses for patients at risk (strong recommendation) 1
   • Avoid alternating-air mattresses as they show no clear benefit over static mattresses and are more expensive 1
   • Implement regular repositioning every 2-4 hours using 30-degree tilted positions 2
   • For seated patients, use advanced static cushions with viscoelastic properties 2

Wound Management

Stage-Based Treatment Approach

1. Stage 1 (Non-blanchable erythema)

   • Relieve pressure immediately
   • Apply protective dressings (thin film or hydrocolloid)
   • Monitor closely for deterioration

2. Stage 2 (Partial thickness skin loss)

   • Cleanse wound gently
   • Apply hydrocolloid or foam dressings 2
   • Consider electrical stimulation as adjunctive therapy 1, 2

3. Stage 3 (Full thickness skin loss)

   • Perform debridement of necrotic tissue
   • Use appropriate dressings based on exudate level:
     • Minimal exudate: Hydrocolloid dressings 2
     • Moderate exudate: Foam dressings 2
     • Heavy exudate: Alginate or hydrofiber dressings 2

4. Stage 4 (Full thickness tissue loss with exposed bone/muscle)

   • Aggressive debridement
   • Consider negative pressure wound therapy
   • Evaluate for surgical intervention 1, 3

Nutritional Support

• Provide protein supplementation (1.2-1.5 g/kg/day) to enhance tissue integrity and healing 2
• Ensure adequate hydration
• Consider multivitamin supplements, particularly with vitamins C and zinc

Infection Control

• Monitor for signs of infection (increased pain, erythema, purulent drainage, odor)
• Obtain wound cultures if infection is suspected
• Use topical antimicrobials for superficial infections
• Reserve systemic antibiotics for deep tissue infections or cellulitis

Adjunctive Therapies

• Electrical stimulation is recommended to accelerate healing, particularly for stage 2 ulcers 1, 2
• Consider negative pressure wound therapy for deeper wounds
• Light therapy may reduce ulcer size but evidence for complete healing is limited 2

Surgical Management

• Consider surgical intervention for:

  • Stage 3 or 4 ulcers that fail to respond to conservative management
  • Exposed bone, tendon, or joint
  • Extensive tissue loss

• Surgical options include:

  • Debridement
  • Direct closure
  • Skin grafting
  • Local, regional, or free tissue flaps 3

• Note that reoperation rates due to recurrence or flap failure range from 12% to 24% 1

• Dehiscence is more common if bone is removed during surgery 1

Documentation and Monitoring

• Document wound characteristics (size, depth, exudate, tissue type) at each assessment
• Photograph wounds to track progress when possible
• Reassess treatment plan if no improvement is noted within 2-4 weeks

Common Pitfalls to Avoid

1. Relying solely on support surfaces without implementing regular repositioning
2. Neglecting nutritional status which is critical for wound healing
3. Inappropriate dressing selection that doesn't match wound characteristics
4. Delayed surgical consultation for wounds that aren't responding to conservative management
5. Failing to address underlying causes such as malnutrition, immobility, or incontinence

Remember that multicomponent interventions that include standardized care protocols, staff education, designated skin champions, and regular audits have been shown to improve outcomes and reduce pressure ulcer rates 1.