• Otherwise known as: Pressure ulcer, Decubitus ulcer, pressure sore
• Definition - Breach in the skin conitnuity occurring d.t. molecular death of the cells, caused in immobile elderly patients, requiring chronic health care.

• Common sites - elbows, hips, heels, base of back, lateral malleoli.
• 95% of bed sores occur on lower ½ of body.
• May cause death of the patient directly or indirectly.

• Mechanisms of formation :
  1. Pressure - constant pressure especially over a bony prominence for 2 hours will cause irreversible tissue necrosis.
  2. Shearing forces - sliding up or down over the bed or chair.
  3. Moisture - persistent moisture d.t. urinary incontinence or perspiration.

• Risk factors :
  1. Immobility - elderly debilitated patients, para/quadriplegics.
  2. Poor general condition - Anemia, hypoprotenemia, Vitamin deficiency (A & C).
  3. General diseases - DM, malignancies
  4. P.V.D.
  5. Moisture d.t. urinary or fecal incontinence.
  6. Infection
  7. Senile skin changes.
  8. Dry skin.

Risk of patients developing sore can be judged by scales like the NORTON scale, or the BRADER scale to predict pressure sore risk.

• Pathology : 95% cases have ulcer in lower part of body.
• HPE shows extensive necrosis in the affected part.

• C/F :
  • Patient is elderly, commonly female.
  • Disease occurs in 4 different stages:
    1. Stage 1 - Erythema; not blanching, warmth, tenderness.
    2. Stage 2 - Skin breakdown limited to dermis. More tissue oedema, more sharply defined erythema.
    3. Stage 3 - Skin breskdown limited to subcutaneous tissue. Ulcer crater formation with slough & eschar.
    4. Stage 4 - Ulcers extend beyond deep fascia into muscle, bone. Sepsis, osteomyelitis may occur. Surrounding tissue shows granulation tissue.

• D/D :
  • Ischemic / stasis ulcers
  • Vasculitis
  • Skin condition - pyoderma gangrenosum
  • Radiation injury
  • Malignancy

• Investigations :
  1. Discharge / pus smear & culture & sensitivity.
  2. WBC - TLC & DLC if fever present.
  3. Urinanalysis, urine culture, blood culture.

• Treatment :
  • General measures :
    1. High protein, high calorie diet.
    2. Supplements - FSFA, Vitamins A, C, B12, Zinc
    3. Blood transfusion if severe anemia.
    4. Good nursing - position change every 2 hrs, special beds or coverings over the beds like wools, etc.
    5. Treat the urinary or fecal incontinence.

• Specific treatment :

A Stage 1 :

• Relief of pressure.
• Keep skin areas clean & dry.
• Skin cream over eryhematous areas.
• Assess skin 8-12 hrly.

B Stage 2 :

• Clean sore with gauze soaked in saline / peroxide.
• Dry thoroughly after each cleaning.
• Protective barrier cream to unbroken surrounding skin.
• Occlusive hydrocolloid dressing.
• Dressing every 3 days.

C Stage 3 :

• Clean & dry sore as above.
• Debride with dry gauze.
• Protective barrier cream to surrounding unbroken skin.
• Occlusive hydrocolloid dressing.
• If exudation +++ - absorbent dressing - changed frequently.

D Stage 4 :

• Clean & dry as above.
• Apply protective cream to surrounding skin.
• Pack ulcer with moist gauze.
• Outer dressing.
• Definitive surgical treatment like skin grafting, myocutaneous flaps, or primary closure.