Pressure sores or ulcers
🛏️ Pressure ulcers (bedsores/decubitus ulcers) can form within 1–2 hours of sustained pressure.
⚠️ Never leave patients on hard surfaces (e.g. A&E trolleys, X-ray tables) for long periods.
Early detection & prevention are key to avoiding complications.
ℹ️ About
- 📈 Pressure sore development increases mortality risk almost 4-fold.
- 💡 Strongly associated with frailty, immobility, and poor nursing care.
📍 Common Sites
- 👣 Heels, lateral malleoli
- 🦴 Sacrum, ischial tuberosities
- 🦵 Greater trochanters (hips) and other bony prominences
⚠️ Causes (multifactorial)
- ♿ Immobility (e.g. post-stroke, prolonged bed rest)
- 🧠 Dementia or cognitive impairment
- 🧬 Neurological disease: MS, spinal cord injury, cauda equina
- 🩸 Comorbidities: diabetes, anaemia, malnutrition
- 💧 Incontinence → skin maceration
- ⬇️ Peripheral neuropathy → unperceived pressure
- 💊 Medications: steroids, sedatives, analgesics, anticholinergics
- ⚡ Shear forces, moisture, friction
🩺 Clinical Assessment
- 🧠 Assess mental status & comorbidities
- 🥗 Review nutrition, BMI, hydration
- 🦵 Full neurological exam (motor & sensory)
- 🫃 Abdominal & bowel/bladder function (esp. if incontinent)
📊 Grading of Pressure Ulcers
| Grade |
Description |
| Grade 1 |
Intact skin, non-blanchable erythema over bony area. May feel warmer or firmer. In dark skin, redness may be harder to spot. |
| Grade 2 |
Partial-thickness dermis loss → shallow red-pink ulcer or blister. |
| Grade 3 |
Full-thickness skin loss → visible fat but no exposed bone/muscle. May have slough. |
| Grade 4 |
Full-thickness tissue loss with exposed bone, tendon, or muscle. Often undermining/tunnelling. |
| Unstageable |
Depth obscured by slough/eschar (yellow, brown, black). True grade unclear until debridement. |
🔎 Investigations
- 🩸 FBC → anaemia or ↑WCC (infection)
- 🧪 U&E → renal status, albumin (nutrition)
- 🍬 Glucose → screen for diabetes
- 🔥 CRP → infection/chronic inflammation
- 🧫 Wound swab → culture & sensitivity if infection suspected
- 🧪 Blood cultures if septic
- 🩻 X-ray/MRI → rule out osteomyelitis under chronic ulcers
⚠️ Complications
- 🦴 Osteomyelitis → infection of bone beneath ulcer
- 🧬 Sepsis → systemic infection, life-threatening
- ➡️ Chronic non-healing ulcers → pain, poor QOL, repeated admissions
💊 Management
- General Care: Debride necrotic tissue, regular repositioning, air/pressure-relief mattresses, meticulous wound care
- Risk Assessment: Use Braden or Norton scale to identify high-risk patients; optimise diabetes, nutrition, anaemia
- Pressure Relief: 2-hourly turns, heel protectors, special cushions, bed cradles
- Debridement: Remove slough/eschar to promote granulation and accurate staging
- Infection Control: Target organisms: Proteus, Strep D, E. coli, Staph, Pseudomonas. Treat cellulitis/sepsis promptly with systemic antibiotics
- Nutrition: Optimise protein, vitamins (C, A), zinc, hydration
- Dressings: Moisture-retentive, antimicrobial or proteolytic debriders depending on wound bed
- Surgery: Stage III/IV may need grafts, flaps, or plastic surgical input
📌 Exam Pearl:
– Grade 1 = erythema, intact skin.
– Grade 4 = exposed bone/muscle.
– Always reposition immobile patients every 2 hours to prevent sores.
– Healing requires pressure relief + nutrition + infection control.
📚 References
