Pressure Sores
Victor Lewis, M.D.
Pressure sores continue
to be a major problem in the elderly and, despite some improvement
in application of preventive techniques, will continue to be a
major problem in the future.
- Patients at risk have
limitations of mobility, sensation and mentation, or incontinence
of urine or stool. Evaluate possibility for turning and positioning
in pre-hospitalization environment.
- The most common sites
of pressure sores are the sacral, ischial and trochanteric bony
prominences. Diagnosis requires inspection of the supine patient's
back and all pressure points.
- Pressure sores are clinically
graded I-IV by depth (Shear). Grade I describes erythema with
intact skin. Grade II wounds have broken skin but intact subcutaneous.
Grade III wounds involve the deep soft subcutaneous tissue under
the skin but not muscle. In Grade IV wounds, tissue is lost to
the bone including intervening soft tissues.
- In spite of appearance,
pressure sores are usually not a primary source of sepsis. Evaluate
all sources of sepsis in the febrile patient. Even if the pressure
sore needs debridement, it is probably not a source of sepsis.
- Biopsy cultures are
preferred to swab cultures for microbiological data, and can
be obtained during debridement. Bone biopsy is a reliable way
to assess status of bone, inexpensive, and yields better data
than Technictum scans.
- Initial management limits
additional tissue trauma through positioning, use of low air
loss, or air fluidized environments, to relieve pressure.
- Saline moistened gauze
under dry pads held in place by net dressings is appropriate
primary local wound care, usually changed three times a day.
Use moist Kerlex (not loose gauze) on large wounds.
- Evaluate the likelihood
of useful data on the state of the underlying bone from tomography
or scans. Frequently, the diagnosis of osteomyelitis can be made
by bone biopsy at the time of debridement. Osteomyelitis must
be diagnosed before healing can be achieved by operative or conservative
means. All wound products (dextramomer, calcium alginate, membrane
and gel wound coverings) are approved as devices substantially
similar to gauze for wound coverage. Consider cost vs. goal of
dressings, gauze vs. other mechanisms in care.
- The possibility or value
of operative wound closure must be considered. Will operation
improve patient comfort, upgrade the site of care, make possible
a more active lifestyle, improve nutritional status?
Indications for consultation
Consultation with the nursing specialists and plastic surgery
service can assist in evaluation and management of pressure sores.
They can help you when debridement, biopsy or closure are indicated
and can give advice about the many products and therapies, comparing
and contrasting costs vs. goals of treatment.