Are You Confident of the Diagnosis?
Characteristic findings on physical examination
The diagnosis is made by observation (Figure 1, Figure 2, Figure 3). An ulcer reflects a break in the skin that can even extend to the underlying bone.
Expected results of diagnostic studies
An ulcer requires no overt diagnostic studies; however, for suspected osteomyelitis, an X-ray and magnetic resonance imaging (MRI) are indicated. For accompanying infection, bacterial cultures and sensitivities are needed.
–Diabetic neuropathic ulcer – diabetic patient with peripheral neuropathy, typically on the foot.
–Arterial ulcer – arterial blockage causing tissue necrosis located on ankle or foot.
–Venous insufficiency ulcer – impaired venous return causing venous stasis dermatitis/ulcers, typically found on pretibial area or above medial malleolus.
–Cellulitis – skin infection may mimic an early decubitus ulcer (intact skin with nonblanchable redness)
–Pyoderma gangrenosum – early stage with redness and induration or slight ulceration on the edge may be indistinguishable
The diagnosis is a clinical one, not requiring laboratory studies or histopathologic confirmation. In reality, the decubitus ulcer is a diagnosis of exclusion after the conditions listed under differential diagnosis are excluded.
Who is at Risk for Developing this Disease?
Epidemiology: The elderly; neurologic patients with such diseases as multiple sclerosis or amyotrophic lateral sclerosis; patients sustaining trauma that includes spinal cord injury; and patients subjected to lengthy operations. No gender difference exists.
Scales: A number of scales are used by nursing personnel, including the Norton and Braden scales, to aid in predicting which patient may develop a skin breakdown (Table 1, Table 2). Each of the scales has its deficits and is not 100% accurate.
|The Norton Scale*|
|Physical Condition||Mental Condition||Activity||Mobility||Incontinent|
(3)Walk w assistance
(1)Urine and Feces
|The Braden Scale*|
|Sensory Perception||(1)completely limited||(2) very limited (responds only to painful stimuli/can’t feel pain over half of body||(3)slightly limited (responds to verbal commands/can’t feel pain in one or two extremities)||(4)no impairment|
|Moisture||(1)constantly moist||(2)moist often but not always||(3)occasionaly moist||(4) rarely moist|
|Activity||(1)confined to bed||(2)confined to chair||(3)walks occasionally||(4)walks frequently|
|Mobility||(1)completely immobile||(2)very limited (occasional changes in position)||(3)slightly limited (frequent/slight changes in position)||(4)no limitation|
|Nutrition||(1)very poor (never eats a complete meal)||(2)probably inadequate (eats less than half of balanced meal)||(3)adequate (eats over half of balanced meals)||(4)excellent|
|Friction and Shear||(1)problem (requires assistance in moving)||(2)potential problem (minimal assistance in moving)||(3)no apparent problem|
* Adapted from Parish LC, Witkowski JA, Crissey JT. The decubitus ulcer in clinical practice. New York: Springer Verlag; 1997.
|Decubitus dermatitis including bullae|
|Stage I||Nonblanchable erythema of intact skin|
|Stage II||Full-thickness loss of skin involving epidermis/dermis|
|Stage III||Full-thickness loss of skin including subcutaneous tissue that may extend down to underlying fascia|
|Stage IV||Full-thickness loss of skin including subcutaneous tissue, muscle, bone, or supporting structures (eg, tendons or joint capsule)|
* Staging acording to the National Pressure Ulcer Advisory Panel (NPUAP)
What is the Cause of the Disease?
Pressure over bony prominences, shearing force, destruction of skin, and compromised blood flow. Contributing factors include malnutrition, infection, and underlying disease.
Systemic Implications and Complications
–Incontinence – fecal or urinary
–Tissue Ischemia – hypotension, dehydration, vasomotor failure, vasoconstriction secondary to shock, heart failure, medications
–Neurologic disease – dementia, delirium, spinal cord injury, neuropathy
|Medical Options||Surgical*||Physical Modalities|
Wound infection – topical antibiotics only if infection is present
Decubitus dermatitis – topical corticosteroids
Dressing – alginates, foams, hydrofibers; saline moistened gauze, transparent films, hydrocolloids, hydrogels
Scalpel or scissors
Autolytic with an occlusive dressing
Wound infection – systemic antimicrobials, only if infection is present
Appropriate nutritional intake (enteral/parenteral nutrition, if needed)
Dynamic support surfaces: air-fluidized mattress, low air loss bed, alternating pressure mattress
Static support surfaces: Foam support surfaces and Overlays (foam, air, water)
* Although nursing personnel often recommend turning every 2 hours, there is no evidence that specified internvals for turning are useful.
Optimal Therapeutic Approach for this Disease
Is infection present? Determined by classic signs, such as redness, pain, purulent discharge. If present, discharge treat infection.
If necrotic tissue is present, debridement is often needed to promote healing by removing the barrier to reepithelialization
Begin with nonselective methods (surgical debridement, mechanical abrasion, wet-to-dry dressings, forceful irrigation)
Progress to selective methods as necrotic tissue is removed (partial surgical, autolytic, enzymatic, chemical, biosurgical debridement)
Occlusive dressings (hydrocolloid) providing moist environment and accelerating healing.
Repositioning schedule – no evidence supports specific timing, but public opinion deems a 2-hour turning schedule in the United States and 3 or more hour intervals in the UK.
Specialty beds – alternating pressure air mattress, air-fluidized beds.
Proper nutrition – no solid evidence supporting use of supplements, but proper caloric intake is important to promote healing. While zinc-depleted patients may have poor wound healing, there is no evidence to show adding oral zinc prevents or heals ulcers. Similarly, ascorbic acid neither prevents nor promotes wound healing in these patients.
Treated but not necessarily prevented. The patient’s underlying condition(s) are the significant factor(s). Some patients no longer have the ability to heal a wound.
Unusual Clinical Scenarios to Consider in Patient Management
Decubitus ulcers may take some time to appear. Sometimes, they are suddenly recognized. This does not mean that they developed overnight; rather, there may be the volcano effect, whereby the destructive process finally reaches the surface and can now be visualized.
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