sores (decubitus ulcers) affect 20% of terminally ill
patients. They occur over bony prominences and weight-bearing
areas, most commonly sacrum, hips, heels (but also elbows,
spine, side of knee, ears and back of head).
There are two types:
Superficial (capillary damage)
(large vessel damage)
Superficial sores begin with capillary damage. They can
occur on normal skin if excess pressure is applied (within 30
minutes on a hard surface for an elderly patient or a
diabetic). They are painful. They can become deep if
sores (usually seen only in chronically bedridden
patients) start with deep tissue damage. The overlying skin
appears intact until it dies and breaks down to reveal a large
necrotic cavity. They are full thickness from the beginning
and can go down to bone. They are rare in terminally ill
patients and will not be discussed further.
Pathophysiology Pressures on the skin above 30mm Hg
(capillary blood pressure) cause tissue damage. After 1 to 2
hours there is irreversible cell damage. Early redness
(hyperemia) which still blanches on digital pressure (showing
the capillaries are intact) will reverse after 4 hours of
pressure relief. Non-blanching hyperemia takes 48 hours of
pressure relief to reverse.
Pressure damage occurs more rapidly if the skin is also
subject to friction (skin damage) or lateral shearing forces
(capillary damage) - both of which occur if patients are
pulled instead of lifted. All carers should be taught the
correct techniques of lifting and turning.
Prevention is better than cure (which is often impossible).
The principles of prevention are relief of pressure and
friction, which are aided by the following:
Whirlpool baths (to relieve pressure)
Careful lifting and turning (to avoid friction or shear)
Regular turning in bed (at least every 2 hours)
Sheepskin mattress and chair covers
(siliconized) mattress covers to reduce friction
or water mattresses
and elbow protective siliconized pads
baby sponge taped onto the sacrum (and changed regularly) can
bring considerable relief when a bony sacral prominence makes
ring cushions which restrict blood flow and increase the risk
of tissue damage.
Specialized dressings promote healing only if pressure is
concept of moist wound healing was developed in the 1960s. The
aim of these newer specialized (and expensive) dressings is to
accelerate healing by promoting the ideal micro-environment in
terms of temperature, moisture and oxygen supply, and by
preventing adherence which damages new granulation tissue.
Stage of Damage
Yellow exudate and cavitation
Absorbent dressing plus foam covering
Black necrotic tissue
Irrigate with streptokinase and treat as in #3
Semi-permeable membranes (Opsite, Bioclusive, Tegaderm)
are useful for early pressure areas with little exudate,
particularly on elbows, hips and insides of the knees. They
can reduce pain. The membrane is waterproof and protects the
skin if there is incontinence. It can be used successfully on
the sacral area but it needs to be skillfully applied.
must be carefully cleaned to remove skin grease, avoiding
broken skin and the anal margin. Two carers are needed: one to
hold the skin tight and the other to apply the membrane.
Several overlapping pieces may be needed to cover awkward
areas. A piece of stomahesive plaster cut to a triangle can be
used to fill the sacral cleft. If the membrane is applied
unevenly it can cause friction and more damage.
amounts of exudate can be aspirated with a needle (the hole is
sealed with another piece of membrane). Larger amounts of
exudate prevent the membrane from adhering.
Unfortunately, a significant number of patients develop an
allergic reaction to these membranes.
Impermeable hydrocolloid dressings (Duoderm, Comfeel) are
occlusive, adhesive and waterproof. They have an inner layer
that converts to gel when in contact with wound exudate. This
provides a good environment for moist wound healing. The lack
of oxygen transfer promotes formation of granulation tissue.
The indications for use are:
dressing should overlap normal skin by 3cm to 4cm. It can be
used alone as it is adhesive. It is changed when the liquid
becomes visible as a yellow bubble (when the dressing begins
to disintegrate). It can be left in place for 4 to 5 days, but
may need changing more frequently. On changing the dressing,
yellow gel may be found on the wound surface. This is normal
(it is not pus) and should be washed off with normal saline.
brands of dressings vary in pliability and absorbency.
Alginate dressings (FDA approval pending for Kaltostat,
Kaltocarb) are particularly useful in promoting healing of
deeper pressure sores. The dressings are highly absorbent and
convert to a gel which promotes moist wound healing. It is
important to pack loosely.
material conforms to the cavity and is non-adherent and easily
washed off with normal saline. It is also hemostatic and
controls capillary bleeding. It can be used to hold fluid
(such as metronidazole to control smell) in contact with the
wound. It needs a secondary covering, preferably a foam
dressings need to be changed daily.
dressings (Lyofoam, Synthaderm) absorb excess exudate and
maintain a warm, moist environment conducive to healing.
Lyofoam-C is impregnated with activated carbon to reduce
smell. The foam should overlap the wound by 3cm and is held
down by hypoallergenic adhesive tape.
Absorbent powders (Debrisan beads, Duoderm granules) and
pastes (Debrisan Wound Cleaning Paste) are occasionally useful
if there is a large quantity of exudate. These can cause
discomfort. If used excessively they dry out the wound and can
be difficult to remove.
necrotic tissue delays healing and can become infected causing
odor. Enzymatic debridement with streptokinase is
better than using acidic desloughing agents which can damage
granulation tissue. Streptokinase is expensive, but it is
superior to chemical debriding agents, and is only
occasionally needed. Streptokinase can be applied on an
alginate dressing. A dry hard black area (on the heel, for
example) can be softened and removed by applying a
It is important to understand that a pressure area will heal
if it is kept clean and relieved of pressure.
can be enhanced by some of the newer dressings which
promote moist wound healing but only if pressure-relieving techniques are adequate.
irrigation of pressure sores with warm saline is
recommended to remove exudate. Antiseptics can delay healing.
Infected or smelly exudate is best removed with 10% Betadine
solution, diluted to 5% with normal saline to avoid damage to
new tissue. (Avoid hypochlorites which damage
remedies like sugar, honey, oxygen, wine or egg white. There
is no evidence that they help, and they distract from the
essential treatment, which is pressure relief.
Pressure relieving aids (specialized cushions, mattresses
or beds) are useful for both prevention and treatment. A large
cell ripple mattress, properly inflated, will reduce interface
pressures between skin and surface, as measured by pressure
sensors. Sequentially inflated chamber mattresses can reduce
pressure enough to heal pressure sores without turning the
patient. However, the effect of surface pressure on capillary
flow remains poorly understood. More study of preventive
techniques is needed to develop optimum methods.
Physical methods of treatment are sometimes used (in
addition to pressure relief) to promote granulation tissue and
speed healing. They include ice therapy (to reduce the skin
edema in early pressure areas with redness only), ultraviolet
light, ultra-sound, ionized water vapor and pulsed high-frequency energy. (These methods should not be used to
deslough or treat infected wounds.)
massage which can increase skin damage any benefit it
seems to have is due to associated pressure relief.
Surgical excision of black necrotic tissue may be
necessary to reduce infection and smell. Pain in a deep
pressure sore is unusual and suggests pus under a necrotic
slough, which can be painlessly excised without local
anesthetic to release the pus.
There is some evidence that oral zinc (such as zinc
gluconate tablets) improves skin healing. Zinc is an essential
trace element, and it is low in 80% of patients with chronic
treatment of pressure sores it is logical to give Vitamin C
daily if nutrition has been poor for several months. Vitamin C
is essential for the maintenance of healthy collagen and
connective tissue in skin. White cell Vitamin C levels are low
in 70% of patients with chronic disease.
spectrum antibiotics with anti-staphlococcal action should be
given if there is cellulitis.
Comfort care Even with a short prognosis of a few weeks,
wound healing may still be an important aim (to maintain
positive attitudes for both patient and carers). During the
last few days of life wound healing is secondary to comfort.
and effective management of superficial pressure sores in the
last few days of life can be achieved with one of the barrier
creams, applied generously and covered with soft gauze. It is
cooling and soothing, and reduces friction and lateral
shearing forces on the skin. Combined with pressure-relieving
techniques it can still produce gradual healing of the skin.
Turning routines should be relaxed in the terminal phase if
the patient is most comfortable on one side, or if turning
find washable Spenco (siliconized fiber) mattress covers very
comforting, as these reduce pressure and lateral shearing
The author and publisher have taken
precautions to ensure that the information in this book is
error-free. However, readers must be guided by their own
personal and professional standards of good practice in
evaluating and applying recommendations made herein. The
contents of this book represent the views and experience of
the author, and not necessarily those of the publisher.