EXPLANATION OF DECUBITUS ULCERS OR PRESSURE SORES
LDHP Medical Review Services Corp.
Linda Pershall, RN, BSN

In most situations decubitus ulcer formation is preventable and not excusable. Accepting decubitus ulcer formation as inevitable does not facilitate an environment of optimum care.

A decubitus ulcer is a pressure sore or what is commonly called a bed sore or pressure ulcer. 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 internal organs and into bone. These ulcers or wounds are classified according to the severity of the wound, usually in four stages or types. [See the wound stage page for more details].

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 a lot of blackened tissue in it such as a third or fourth degree burn. This black tissue is called eschar. A decubitus ulcer can develop in as little as eight hours in an immobile, debilitated person.

MECHANISM OF WOUND 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 very likely to form a decubitus ulcer. These areas include the spine, coccyx or "tailbone," hips, heels, and elbows, to name a few. The weight of the person's body presses on the bone, the bone presses on the skin and tissue that cover it, and the tissue is trapped between the bone structure and bed or wheelchair surface. This situation compresses the blood vessels in the skin and underlying tissues. This tissue then begins to decay from lack of blood circulation. This is the basic mechanism for the formation of decubitus ulcers.

A contributing factor to the development of decubitus ulcers is an altered nutritional state [poor nutrition, weight loss, diabetes, etc.]. Additional contributing factors are poor hygiene, dehydration and immobility sometimes as a result of a poor standard of nursing care to name a few. Diabetes is not a cause of decubitus ulcers but rather unrelieved pressure is the cause however in a diabetic individual the situation may escalate more quickly an be more difficult to control. For this reason diabetic individuals need even greater attention and prevention than non-diabetic individuals.

NURSING CARE, PREVENTION AND TREATMENT OF DECUBITUS ULCERS

The common areas for the formation of decubitus ulcers and their prevention is a basic area covered in all nursing schools by all licensed nursing programs (LVN or RN). Prevention consists of changing the person's position every two hours or more often if needed. The two-hour time frame is a generally accepted maximum interval that tissue can tolerate pressure without damage. Prevention also consists of protection and padding to prevent tissue abrasion as well as the elements of nutrition, hydration, hygiene, etc. Turning and positioning is common knowledge for physicians, licensed nurses (LVN or RN), physical therapists as well as paraprofessional care gives (nursing assistants). Turning is applicable even on flotation mattress beds.

Treatment for decubitus ulcers involves removing all pressure from the involved area(s) to prevent further decay of tissue and promote healing. Frequent turning is MANDATORY to alleviate pressure on the wound and to promote healing. Treatment also involves keeping the area clean, promoting tissue regeneration and removing necrotic (dead) tissue, which can form a breeding ground for infection. There are many procedures and products available for wound care, cleaning and pressure reduction. The use of antibiotics when appropriate is also part of the treatment. Some deep wounds even require surgical removal or debridement of dead tissue. Without all of these elements being in place, the wounds will NOT heal and, in fact, will QUICKLY WORSEN.

PREVENTIVE EQUIPMENT AND PROCEDURES

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. The devices available include foam padding, sheep-skin like padding for wheelchairs, air mattresses, silicon gel pads, sponge rubber mattresses (egg crate), and very specialized flotation beds to name a few. One example of such a specialized flotation bed device is a "Ken-Air Bed." These beds are used in hospitals, nursing homes and private homes by families. They can be a Medicare/Medicaid/Insurance-covered item when medically necessary. Most insurances will cover any needed device, material, or equipment necessary to prevent and treat decubitus ulcers as it is far more cost effective and humane to prevent these wounds than to treat them.

The United States Department of Health and Human Services publishes a clinical guideline for pressure ulcers prevention and treatment. *

STANDARDS OF CARE

It remains true that decubitus ulcers are generally considered preventable and the development of decubitus ulcers is generally evidence of some form of deviation in the standard of care (neglect) usually nutrition, hydration, hygiene, positioning or infection control. 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 in these home care settings. PREVENTION IS GENERALLY ACHIEVED BY DILIGENT CARE.

DECUBITUS ULCER FORMATION AND TREATMENT IN LONG -TERM CARE FACILITIES

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 would dictate.

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 within two weeks. This is considered adequate although not ideal 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. Patient's 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 well. This is not necessarily a breach in the standard of care but this is also very rare. It is possible to greatly reduce pressure ulcer development by frequent turning and appropriate padding even in terminal situations were a patient is not receiving nutrition and hydration.

SUMMARY

In most situations decubitus ulcer formation is preventable and not excusable. Accepting decubitus ulcer formation as inevitable does not facilitate an environment of optimum care.

In almost all situations, the development of massive decubitus ulcers is evidence of some form of deviation in the standard of nursing care (neglect). Generally the neglect is in more than one area, i.e., hygiene, nutrition, infection control, protection and positioning. It would be a very rare exception for this to not be true.

*1. "Pressure Ulcers in Adults: Prediction and Prevention" Clinical Practice Guideline Number 3, May 1992

2. "Treating Pressure Sores" Consumer Version, Clinical Practice Guideline Number 15, December 1994

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