For the hospitalized patient, prevention of pressure ulcers requires vigilant surveillance by a dedicated care team. It is estimated that 10–15% of patients who are in the ICU for one week develop a pressure sore. Nursing-home patients have a 10–30% prevalence of pressure ulcers, whereas spinal cord injury patients have a 50–80% lifetime risk. Numerous patient factors, including malnutrition, obesity, smoking, immobility, diabetes, neurologic injury, and hip fractures, are associated with the development of pressure ulcers. Prolonged pressure with resultant tissue ischemia, shear stress, and edema all lead to tissue necrosis. Moisture and infection are factors which may cause additional progression of severity. Pressure ulcers typically occur over bony prominences where pressure and shear stress are the greatest. The most common sites are found over the ischial tuberosities, sacrum, greater trochanters, and heels. Without prompt recognition and treatment, pressure ulcers will progress through stages of increasing tissue damage. Table 94.1 shows the current pressure ulcer staging system, which is based on gross appearance.
Stages I and II will usually resolve with conservative treatment including topical creams, such as silver sulfadiazine, frequent changes in patient position, air fluid beds, protective bandages, and improved nutrition. Few stage III ulcers can be treated effectively with conservative measures and progression to stage IV generally requires operative intervention. Effective management requires a multidisciplinary team including nurses, dieticians, physical therapists, social workers, and surgeons. Because of the difficulty in treating these wounds and the high rate of recurrence, prevention is of paramount importance. Frequent weight shifts to relieve pressure, proper hygiene, optimal nutrition, and primary education are important measures for prevention.