Review Question - QID 105655

This bedbound elderly man presents with sacral and malleolar pressure ulcers, which are best prevented with frequent repositioning.

A pressure ulcer is a localized injury to the skin and/or underlying tissue. Pressure ulcers occur most frequently over bony prominences, including the sacrum, ischial tuberosities, and malleoli. Risk factors include limited mobility, poor nutrition, and poor skin care. Treatment requires repositioning and protection (stage I), maintaining a moist wound environment (stage II), or debridement and management of infection (stage III/IV).

Bluestein and Javaheri review pressure ulcer prevention and management. Preventative measures should be utilized in at risk patients. Important measures include efforts to reduce pressure, which helps preserve tissue perfusion. Pressure off-loading devices can be useful in this capacity. Additionally, frequent repositioning is important to reduce pressure ulcer incidence. No optimal repositioning schedule has been defined, but every two hours is frequently recommended.

Gefen et al. discuss staging of pressure ulcers. Pressure ulcers are currently classified by severity into six categories, which include stages 1-4, as well as deep tissue injury (DTI) and unstageable. Stage 1 pressure ulcers are described as localized areas of nonblanchable erythema with intact skin. Stage 2 involves skin breakdown, stage 3 involves the underlying tissues, and stage 4 extends to the muscle or bone.

Illustration A is an artistic representation of stage 1-4 pressure ulcers. Illustration B depicts photographs of stage 1-4 pressure ulcers in affected patients. Illustration C depicts areas that pressure ulcers typically occur for a given patient position.

Incorrect answers:
Answer 1: Lower bed elevation (less than 30 degrees) is recommended, as this reduces shear force, which thereby reduces risk of pressure ulcer.
Answer 2: Per Bluestein and Javaheri, poor nutrition is associated with pressure ulcers in some studies, but a causal relationship has not been definitively demonstrated. Moreover, improving nutrition is less likely to prevent ulcers than frequent repositioning.
Answers 3-4: Topical antibiotics and/or anti-coagulants do not prevent pressure ulcers.