Combating Decubitus Ulcers: Strategies for You and Your Patient

Pain, disfigurement, prolonged hospital stay: these are among the consequences of decubitus ulcers. Although these ulcers can be difficult to manage, prompt therapeutic action can prevent complications, such as cellulitis, sinus tract or abscess, and sepsis, and can help promote healing.

The development of a single pressure ulcer in a hospitalized patient can increase the cost of the stay by $2000 to $11,000.¹ The toll (financial, physical, and emotional) can be markedly reduced if an effective prevention and treatment strategy is followed. Highlights of guidelines for assessing and managing pressure ulcers are presented here.^1-3

YOUR ROLE

Although the actual management of tissue loads (distribution of pressure, friction, and shear on the affected area) generally falls to the nursing staff, patient, and family members, you need to spearhead efforts to attenuate these ulcers. Start by assessing the patient’s overall health and nutritional status. Risk factors for pressure ulcers include loss of functional independence, smoking, alcohol consumption, urinary and fecal incontinence, and poor nutrition.⁴ Because these ulcers frequently occur in malnourished persons, your goal is to ensure that the patient’s diet contains enough nutrients to support healing.

Provide nutritional support. Recommend dietary supplementation if your patient is poorly nourished, and prescribe vitamins and minerals if you suspect a deficiency. If dietary intake continues to be inadequate, or if the patient cannot feed himself or herself, provide nutritional support (usually via tube feeding) to restore positive nitrogen balance. This generally involves administration of 30 to 35 calories/kg/d and 1.25 to 2 g/kg/d of protein.

Assess the ulcer. After an overall assessment, focus in on the location, stage (Table), and size of the decubitus ulcer. Determine whether there are sinus tracts, undermining, tunneling, exudate, necrotic or granulation tissue, or epithelialization.

Alleviate the pain. This is best done by removing or controlling the source of the pain, and/or by providing analgesia. Pain may be relieved by covering the wound, adjusting support surfaces, and repositioning the patient. Caregivers must try not to exacerbate the pain during dressing changes and debridement.

Evaluate psychosocial status. Your goal is to gather enough information to formulate a plan of care consistent with the patient’s and family’s preferences. The patient’s ability to understand and adhere to any treatment program clearly depends on his mental status, ability to learn, and social support system. Alcohol or drug abuse and polypharmacy can all impair patient compliance.

Reassess regularly. Reevaluate ulcers at least once a week for signs of deterioration that would warrant alteration of your treatment plan. If you see no evidence of healing within 2 to 4 weeks, therapy also needs to be modified. Determine, for example, whether tissue-load management is adequate as well as the extent of adherence to cleansing, dressing, and nutritional support interventions. If the ulcer is not healing, look for underlying necrosis or abscesses; if found, these must be drained. Promptly treat associated infection or osteomyelitis.

THE PATIENT’S ROLE

Effective management also depends on the extent to which patients participate in their own care. After your initial assessment is completed, enlist the help of the patient’s family and other caregivers by discussing treatment options and developing with them a plan of care that is consistent with the patient’s own goals and wishes.

You might also offer these recommendations to your patients and their caregivers:

Use support surfaces. These include special beds, mattresses, mattress overlays, and seats that cushion vulnerable areas of the body and protect them from prolonged weight bearing.

Change position as often as possible. Bedbound patients should:

•Avoid lying on the pressure sore. (A foam pad or pillow is needed to support the back and knees.)

•Keep heels off the bed by placing either a thin foam pad or pillow under the legs from midcalf to ankle.

•Try to avoid putting weight directly on the hip bone; shift the weight to a pillow instead.

•Raise the head of the bed by about 30 degrees.

Patients who are seated for long periods should be advised to:

•Avoid doughnut-shaped cushions; these slow blood flow to the tissue.

•Shift position every 15 minutes. If the patient cannot move himself, have someone help him change position at least once an hour.

Eat well. Let the patient know that poor nutrition contributes to poor healing. Stress the importance of a balanced diet in combating pressure sores.