How To Diagnose And Treat Pressure Ulcers

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Continuing Education Course 102– June 2002

I am very pleased to introduce the second article, “How To Prevent, Diagnose And Treat Pressure Ulcers,” in our new CE series. This series, brought to you by HMP Communications, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Obviously, pressure ulcers are a serious problem for many patients. Given the demographic trends on the aging of the population in the United States, having a strong knowledge of pressure ulcer treatment is perhaps more critical than ever before. In this article, Tamara Fishman, DPM, describes the nature of these ulcers, key diagnostic indicators and helpful treatment insights.
At the end of this article, you’ll find a nine-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications. This course will be posted on Podiatry Today’s Web site ( roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Podiatry Today

Sponsored by HMP Communications, LLC.

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 55 and successfully answering the questions on pg. 60. Use the postage-paid card provided to submit your answers or log on to and respond electronically.
ACCREDITATION: HMP Communications, LLC is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by HMP Communications, LLC are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Fishman has disclosed that she has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of her presentation.
GRADING: Answers to the CE exam will be graded by HMP Communications, LLC. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
RELEASE DATE: June 2002.
EXPIRATION DATE: June 30, 2003.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• identify the four stages of pressure ulcers;
• explain the role of nutrition in the healing of pressure ulcerations;
• describe the factors that place a patient at risk for the development of pressure ulcerations;
• identify components of the optimal treatment for pressure ulceration; and
• be familiar with the legal implications of pressure ulcerations.

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Here you can see a pressure ulcer of nine months duration with eschar formation on the left heel. The patient has a history of prostate cancer and peripheral vascular disease.
Pressure ulcers (as shown above) may develop over any bony prominence or any area of the soft tissue that is subjected to periods of prolonged pressure.
To prevent the development of pressure ulcers, the author emphasizes protecting at-risk patients from adverse external forces, friction, shearing and pressure.
By Tamara D. Fishman, DPM

Currently, over 34 million Americans are age 65 and over. This figure is expected to double to over 68 million by the year 2030. As a result, there has been a tremendous growth in nursing homes and the related federal regulations that oversee these facilities. Pressure ulcers are particularly problematic in this patient population. According to the Agency for Health Care Policy and Research (AHCPR) guidelines, the incidence of pressure ulcers (often referred to as bedsores) in long-term care facilities was estimated to be as high as 23 percent in 1989.
Pressure ulcers (also called decubitus ulcers and trophic ulcers) may develop over any bony prominence or any area of the soft tissue that is subjected to periods of prolonged pressure. A pressure ulcer is described as local damage to the skin that is caused by a disruption of the blood supply to the area, usually due to pressure, friction or shear. Pressure is the most critical factor as these ulcers are frequently the result of soft tissue being compressed between bony prominences for an extended period of time. Shear separates the skin from underlying tissues. Friction will abrade the top layer of the skin and will also lead to pressure ulcer formation.
While some literature suggests pressure ulcers may never be entirely eliminated, the development of a new pressure ulcer is considered to be a poor outcome in patient management. However, it doesn’t take long for these ulcers to develop. Indeed, pressure ulcers can form in less than two hours. Therefore, clinicians should be proficient in identifying the high-risk patient in order to prevent the development of pressure sores and associated complications. Patients at risk for pressure ulcers include the following:
• paralyzed patients;
• patients with diminished pain awareness;
• patients who have a chronic illness that requires them to be bedridden;
• those recovering from a hip fracture;
• patients who are dehydrated;
• patients who are malnourished;
• patients who previously had pressure ulcers that healed;
• those with altered mental status;
• those who have incontinence; and
• immunosuppressed patients.

A Few Thoughts About Prevention
Most pressure ulcers are preventable. Even if there is a stage one pressure ulcer, it should not deteriorate in most circumstances. High-risk patients may be a different story as even the most effective nursing care and patient management may not prevent the development and deterioration of ulcers. Nevertheless, we must aim aggressive therapy at reducing the patient’s risk factors and implement preventive measures as well.
In addition to maintaining and improving tissue tolerance, we must protect patients against adverse external forces, friction, shearing and pressure. According to the AHCPR guidelines, one of the keys in preventing pressure ulcers is emphasizing the moving, lifting and turning of patients who are bedridden or in wheelchairs. Patients should be moved every two hours, with small turns in between the positional changes. Also recommend smooth bedsheets and padding for the bed or wheelchair. Patients or their caregivers should also strive to keep the skin clean and dry. Ongoing educational programs can help reduce the incidence of these ulcers as well.

Recognizing The Signs And Stages Of Pressure Ulcers
Keep in mind that an early sign of pressure ulcer development is blanching erythema that you may be able to verify with finger compression. Pressure ulcers often will resolve once you decrease or eliminate the pressure to the area of bony prominence. A non-blanching erythema is a more serious sign that tissue damage is forthcoming or that it may have occurred. A chronic pressure ulceration will have a well-defined border and a surrounding nonblanchable erythema.

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