Assessment of Pressure Ulcers/ Decubitus Ulcers

Introduction

Pressure ulcers or injuries are any breach of skin integrity caused by unrelieved pressure on soft tissue that has been compressed between any external surface and bony prominence for a prolonged prior of time.in addition to pressure, poor blood flow,friction,shear and tissue ischemia can contribute to formation and progress of pressure ulcers.

Persons most at risk are those with conditions that limit their ability to change their positioning bed, suffering debilitating illness, old age and fragility.an assessment must therefore include data related to existing physical condition, illness contributing factors as well as present stage of pressure ulcer.

Risk factors

• Malnutrition.
• Dehydration.
• Impaired mobility.
• Chronic illness.
• Impaired sensation.
• Decreased level of consciousness.
• Advanced age.
• Depressed immune system.
• Peripheral arterial disease.
• Lymph edema.
• Fragile skin.

External contributing factors

• Unrelieved pressure.
• Friction.
• Moisture.
• Incontinence.
• Shear.

Part of body affected

Pressure ulcers form predominantly on skin that covers bony prominences of body parts. Common sites for bed score include:

• Back of the head
• Shoulders
• Back
• Elbows
• Hip
• Inner knees
• Heels

Manifestations / signs

Signs and symptoms and severity vary in different stages of sore:

• Skin discoloration.
• Pain in the affected area.
• Signs of infection.
• Open skin/wound.
• Skin does not tighten to touch.
• Skin softens or firmer than in the surrounding area.

Causative factors

• Prolonged pressure along with other contributing factors.
• Moisture from urine and/or faces.
• Poor circulation.
• Poor nutrition.
• Friction as sheets is dragged from under the patient spear

Stages of Pressure Ulcers

Stage 1: Skin changes in the affected area.

• Skin is not broken but is discolored.
• There is discoloration of the upper layer of skin, commonly the skin color is red, blue or purple.
• The area looks red and may be Warm or cool to touch.
• There may be swelling at the site.
• The affected area may be sore to touch
• There may be mild burning or itching

Stage 2: Ulcer starts developing.

• There may be a blister filled with fluid.
• There may be breakage in the skin revealing a shallow ulcer or erosion.
• The surrounding areas of the skin may be swollen, sore or red.
• Abrasion, blister, or shallow crater develops.
• Fluid seepage or oozing from the skin may be seen.
• Partial thickness wound develops.

Stages 3: Deeper ulcers

• The ulcer extends into the subcutaneous tissue. The area has a crater-like appearance due to damage below the skin’s surface.
• Necrosis (tissue death) and seepage continue.
• Infection develops with signs of foul odor, pus, redness, and discolored drainage.
• The ulcer is much deeper than the full-thickness wound.
•  Fat layer may be involved.

Stage 4: Deeper sores with infection

These sores are most serious. Some may affect muscles and ligaments and manifest as:

• Deep and big sores. The area is severely damaged, and a large wound is often present
• Skin may appear black with signs of infection, red edges, pus, foul odour, heat, and drainage.
• Tendons, muscles, and bone may be visible
• Necrosis.
• Fever in the presence of illness.

Unstageable an Advanced Stages

A dark, hard plaque called eschar may be inside the sore, which makes full evaluation and staging difficult. The ulcer may also have discoloured debris known as slough (yellow, tan, green or brown) which make full evaluation difficult. imaging or surgical evaluation of the area may be required to determine the full extent of the ulcer.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
8. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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