by Linda D. Pershall
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Explanation of Decubitus Ulcers
A decubitus ulcer is a pressure sore or what is commonly called a
"bed sore". It can range from a very mild pink coloration of the skin, which
disappears in a few hours after pressure is relieved on the area, to a very deep wound
extending to and sometimes through a bone into internal organs. These ulcers, as well as
other wound types, are classified in stages according to the severity of the wound.
All decubitus ulcers have a course of injury similar to a burn
wound. This can be a mild redness of the skin and/or blistering, such as a first-degree
burn, to a deep open wound with blackened tissue, as in a third degree burn. This
blackened tissue is called eschar.
MECHANISM OF FORMATION
The usual mechanism of forming a decubitus ulcer is from pressure.
However it can also occur from friction by rubbing against something such as a bed sheet,
cast, brace, etc., or from prolonged exposure to cold. Any area of tissue that lies just
over a bone is much more likely to develop a decubitus ulcer. These areas include the
spine, coccyx or tailbone, hips, heels, and elbows, to name a few. The weight of the
personís body presses on the bone, the bone presses on the tissue and skin that cover
it, and the tissue is trapped between the bone structure and bed or wheelchair surface.
The tissue begins to decay from lack of blood circulation. This is the basic formation of
decubitus ulcer development.
NURSING CARE, PREVENTION AND TREATMENT OF DECUBITUS
The common areas of decubitus ulcer formation and prevention is a
basic nursing principle covered in nursing school curriculum (LVN/LPN or RN) and most
nursing assistant programs as well. Prevention consists of changing position every 2 hours
or more frequently if needed. This 2-hour time frame is a generally accepted maximum
interval that the tissue can tolerate pressure without damage. Prevention also consists of
protection and padding to prevent tissue abrasion, and maintaining hydration, nutrition
The treatment for a decubitus ulcer involves keeping the area clean
and removing necrotic (dead) tissue, which can form a breeding ground for infection. There
are many procedures and products available for this purpose. The use of antibiotics, when
appropriate is also part of the treatment. Some deep wounds even require surgical removal
or debridement of necrotic tissue. In some situations amputation may be necessary.
The second portion of the treatment involves removing all pressure
from the involved area(s) to prevent further damage of tissue and to promote healing.
Frequent turning is mandatory to alleviate pressure on the wound and to promote
healing. Along with cleaning, removal of dead tissue, and alleviating pressure, the
individual must have increased nutrition to allow for proper healing of the wounds.
Without all of these elements being in place, the wounds will not heal and, in
fact, will quickly worsen.
The basic treatment of decubitus ulcers is prevention. Prevention
cannot be stressed too strongly. To this end, there are any number of devices designed to
protect and prevent the formation of decubitus ulcers. The decision of which device to use
is based on the location and severity of the wound. These devices may be a
Medicare/Medicaid/Insurance-covered item when medically necessary. Most insuranceís
will cover any needed device, material, or equipment necessary to prevent and treat
decubitus ulcers. Prevention is the most humane and cost effective approach to care.
STANDARDS OF CARE
It remains true that decubitus ulcers are generally considered
preventable and the development of decubitus ulcers is evidence of some form of neglect
[nutrition, hydration, positioning, infection control, etc]. Many paralyzed or terminal
individuals with very poor nutrition can remain free of decubitus ulcers. This is
accomplished by good patient care often being provided by family members and non-licensed
hired caregivers. Professional medical personnel generally provide only a minimum amount
of medical assistance. Prevention is achieved by diligent care.
Decubitus ulcer formation and treatment in long -term
In long-term care facilities the rate of decubitus ulcer development
is higher for a variety of reasons. Due to staffing shortages, medical funding cuts and an
array of issues, most long-term care facilities are chronically understaffed. This results
in patients not being turned, cleaned and fed as often as the ideal standard of nursing
It is known that almost all decubitus ulcers are preventable.
However the reality of long-term care concludes that if a patient does not have massive
weight loss, chronic infections, or wounds that do not heal in two weeks then that
individual is receiving a reasonable standard of care. It is not uncommon for small wounds
to develop, be treated and heal quickly. This is considered adequate care.
Massive weight loss, massive deep wounds over Stage II and chronic
infections continue to be an unacceptable standard of care. Massive wounds are generally a
strong indication of negligence in more than one area [hygiene, nutrition, infection
control, positioning, etc.].
Another emerging factor in long-term care is patient directed care.
Alert and generally oriented individuals determine their own care. These persons, though
elderly and frail, are not declared incompetent. Patientís rights, as it is currently
practiced, allows for patient refusal of medications, food, fluids and treatments such as
turning. This often results in a lesser quality of care being provided due to patient
noncompliance. When this occurs, the ideal situation is to involve the patient, family,
staff and physician in a plan of care that will be acceptable and beneficial. Patient
refusal of nutrition and positioning may lead to the development of decubitus ulcers as
In summary: In almost all situations, the development of massive
decubitus ulcers is evidence of some form of neglect. Generally the neglect is in more
than one area, i.e., hygiene and nutrition. It would be a very rare exception for this to
not be true.
Decubitus ulcers need to be viewed as a preventable injury, not an
STAGES OF WOUNDS
Wounds are often categorized according to severity by the use of
stages. The staging system applies to burn wounds, Decubitus ulcers and several other
types of wounds.
This stage is characterized by a surface reddening of the skin. The
skin is unbroken and the wound is superficial. This would be a light sunburn or a first
degree burn as well as a beginning Decubitus ulcer. The burn heals spontaneously or the
Decubitus ulcer quickly fades when pressure is relieved on the area.
The key factors to consider in a Stage I wound is what was the cause
of the wound and how to alleviate pressure on the area to prevent it from worsening.
Improved nutritional status of the individual should also be considered early to prevent
wound worsening. The presence of a Stage I wound is an indication or early warning of a
problem and a signal to take preventive action.
Treatment consists of turning or alleviating pressure in some form
or avoiding more exposure to the cause of the injury as well as covering, protecting, and
cushioning the area. Soft protective pads and cushions are often used for this purpose. An
increase in vitamin C, proteins, and fluids is recommended. Increased nutrition is part of
This stage is characterized by a blister either broken or unbroken.
A partial layer of the skin is now injured. Involvement is no longer superficial.
The goal of care is to cover, protect, and clean the area. Coverings
designed to insulate and absorb as well as protect are used. There is a wide variety of
items for this purpose.
Skin lotions or emollients are used to hydrate surrounding tissues
and prevent the wound form worsening. Additional padding and protective substances to
decrease the pressure on the area are important. Close attention to prevention,
protection, nutrition, and hydration is important also. With quick attention, a stage II
wound can heal very rapidly.
A wound can appear to be a Stage I wound upon initial evaluation,
and actually be reevaluated as a Stage II wound during the course of care. Quick attention
to a Stage I Decubitus ulcer or pressure wound will prevent the development of a Stage III
Decubitus ulcer or pressure wound. Generally Decubitus ulcers or pressure wounds
developing beyond Stage II is from lack of aggressive intervention when first noted as a
Stage I. [see notation].
The wound extends through all of the layers of the skin. It is a
primary site for a serious infection to occur.
The goals and treatments of alleviating pressure and covering and
protecting the wound still apply as well as an increased emphasis on nutrition and
Medical care is necessary to promote healing and to treat and
prevent infection. This type of wound will progress very rapidly if left unattended.
Infection is of grave concern.
A Stage IV wound extends through the skin and involves underlying
muscle, tendons and bone. The diameter of the wound is not as important as the depth. This
is very serious and can produce a life threatening infection, especially if not
aggressively treated. All of the goals of protecting, cleaning and alleviation of pressure
on the area still apply. Nutrition and hydration is now critical. Without adequate
nutrition, this wound will not heal.
Anyone with a Stage IV wound requires medical care by someone
skilled in wound care. Surgical removal of the necrotic or decayed tissue is often used on
wounds of larger diameter. A skilled wound care physician, physical therapist or nurse can
sometimes successfully treat a smaller diameter wound without the necessity of surgery.
Surgery is the usual course of treatment. Amputation may be necessary is some situations.
This is an older classification and not now used in all areas. A
stage 5 wound is a wound that is extremely deep, having gone through the muscle layers and
now involves underlying organs and bone. It is difficult to heal. Surgical removal of the
necrotic or decayed tissue is the usual treatment. Amputation may be necessary is some
It is possible for a wound to "go from a stage I wound to a
stage III or IV" without the intermittent stage[s] being observed. All wound stages
were present just not obvious, hence the need to treat all wounds as serious with the
potential of rapidly worsening.