Author(s): Frank Ferris MD and Charles F von Gunten MD
Background This Fast Fact discusses the staging and prevention of pressure ulcers; Fast Fact #41 discusses management. Poor attention to skin care in the dying patient will result in pain, odor, swelling, reduced quality of life and increased care demands for family and other caregivers. Skin can withstand 30-60 minutes of poor perfusion, but not longer. Pressure ulcers result from ischemia due to pressure closing the microarterioles, particularly at pressure points such as the heels, sacrum and elbows. Intrinsic risk factors for ulcer development are limited mobility, conditions that reduce tissue oxygenation, age-related changes in skin, and cachexia. Extrinsic factors are physical forces such as friction, moisture, and shear forces.
Prevention of ulcers is the highest level of care; bedbound patients need to be turned regularly and/or need a pressure-reducing surface. Skin should be protected from friction, moisture and shear. High-risk areas should have either a thin film or hydrocolloid dressings applied.
Stage I. The heralding lesion of skin ulceration is non-blanchable erythema.
Stage II. Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and looks like an abrasion or shallow crater or blister.
Stage III. Full thickness skin loss involving subcutaneous tissue. The ulcer may extend down to, but not through, the underlying fascia. The ulcer looks like a deep crater, with or without undermining of adjacent tissue.
Stage IV. The ulcer is deep enough to include necrosis and damage to underlying muscle, bone, and/or other supporting structures such as tendon or joint capsule. Undermining of adjacent skin and sinus tracts may also be present.
Pressure Reducing Surfaces There are 3 groups of support surfaces that have demonstrated effectiveness; some need to be ordered by a physician.
Air or water mattress overlays (e.g. Roho)— ideal for most patients to prevent pressure ulcers. Order for patients at risk for pressure ulcers.
Low-air-loss beds (e.g. Kenn-air, Dyna-Care, Sof-Care) can be used for high-risk patients or patients with existing ulcers to prevent worsening or to help with healing.
Air-fluidized beds (e.g. Clinatron, Fluid-air) are reserved for patients needing maximum pressure reduction and pressure relief. Patients, however, frequently describe them as overly confining (even “coffin-like”) and they are very expensive (e.g. a Clinitron bed may lease for > $100/day).
Note: Simple foam pads are often ineffective. If they are used, particularly in the home, they should be laid one on top of the other. If a hand is placed under the pads, there should be at least 1 inch of non-compressed foam between the hand and the patient. Never use round cushions (a.k.a. donuts); they occlude blood flow and do not prevent ulcers. Professional assessment and design is needed for special pressure reducing cushions (e.g. for wheelchairs).
Walker P. The pathophysiology and management of pressure ulcers. In:Topics in Palliative Care, Volume 3. Portenoy RK, Bruera E, eds. New York, NY: Oxford University Press; 1998: pp 253-270.
Walker P. Update on pressure ulcers. Principles & Practice of Supportive Oncology Updates. 2000; 3(6):1-11.
Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: firstname.lastname@example.org. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.
Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published August 2005. Current version re-copy-edited March 2009.
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Ferris F, von Gunten CF. Pressure Ulcers: Prevention and Management, 2nd Edition. Fast Facts and Concepts. August 2005; 40. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_040.htm.
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
ACGME Competencies: Medical Knowledge, Patient Care
Keyword(s): Non-Pain Symptoms and Syndromes