Decubitus Ulcer

1. Definition of "decubitus ulcer."

1. It is an area of the skin where lack of blood flow has caused tissue destruction.

2. It is caused by pressure, friction, or shearing (combination of pressure and friction) force on the skin.

2. Anatomy and physiology of the skin.

1. The outer skin, the epidermis, is made up of layered cells. It contains the pigment that makes up skin color.

2. The next layer is the dermis, which contains the oil and sweat glands, hair follicles, blood vessels, and nerves.

3. Below the dermis is the subcutaneous layer, which contains fat cells and connective tissue to act as a shock absorber and insulator for the body.

4. The skin has multiple purposes and functions.

1. Protection against infection.

2. Prevention of loss of body fluids.

3. Control of body temperature.

4. Excretion.

5. Sensation.

6. Production of vitamin D.

7. Esthetic.

3. Factors that may increase the risk of decubitus ulcer.

1. Impaired circulation.

2. Anemia.

3. Immobility.

4. Incontinence of urine and feces.

5. Decreased sense of pain.

6. Poor nutrition.

7. Edema.

8. Excessive moisture.

4. Signs and symptoms of the four stages of decubitus ulcer.

1. Stage I.

1. Redness.

2. Warmth.

2. Stage II.

1. Blister.

2. Superficial break of skin.

3. Stage III.

1. Full-thickness skin break.

2. Subcutaneous tissue exposed.

4. Stage IV.

1. Full-thickness skin break.

2. Muscle and bone exposed

3. Drainage.

5. Areas of the body where breakdown of skin is most likely to occur.

1. Bony prominence such as sacral area, heels, hips, etc.

2. Moist areas such as under breasts, groin areas, etc.

6. Basic principles of wound healing.

1. The force causing the breakdown, shear action, friction, or pressure should be decreased or eliminated.

1. Use pressure-relief devices such as eggcrate mattress, sheepskin, etc.

2. Change positions at least every two hours.

3. Keep linens wrinkle-and crumb free.

4. Care givers should move client with a draw sheet to prevent shearing action.

2. Cleanliness of wound is essential for healing.

1. Wash wound carefully and pat dry.

2. Prevent contamination of wound.

3. Debride wound if necessary.

3. Adequate circulation and nutrition to the wound promotes healing.

1. Eat a well-balanced diet high in vitamins, protein, and minerals. (Provide "Daily Food Guide" and "Protein in Diet" handouts.)

2. Exercise to improve circulation and bring nutrients to the wound.

3. Avoid alcohol and cold temperatures, which constrict blood vessels.

4. A controlled, moist environment promotes healing.

1. Use devices such as tegaderm, duoderm, etc., as ordered by physician.

2. Lubricate dry skin.

3. Use an ointment to protect skin from excessive moisture and incontinence.

7. Possible complications of Decubitus ulcer.

1. Infection of wound.

2. Septicemia.