An 82-year-old man is admitted to a long-term care facility after a right hemiplegic stroke. He is unable to walk and has limited ability to move himself in bed. He is frequently incontinent of urine. He has a past history of type 2 diabetes mellitus. On examination you note a 3-cm area of persistent erythema on the right buttock.
Which of the following treatments would you recommend at this time?a. Sharp surgical débridement to remove the area of erythema
Pressure ulcers are a serious problem in the elderly. They result when skin is damaged by compression between a bony prominence and hard surface for prolonged periods. Pressure ulcers are classified using a standard staging system. A stage I ulcer consists of persistent erythema. A stage II ulcer is characterized by partial-thickness skin loss involving the epidermis or dermis or both. These ulcers are superficial. A stage III ulcer is characterized by full-thickness skin loss involving subcutaneous tissue but not extending through underlying fascia. A stage IV ulcer is a stage III ulcer that extends through fascia and results in damage to underlying structures such as muscle or bone. The treatment of all pressure ulcers includes frequent monitoring of the ulcer, modifying the support surface (such as prescribing a foam mattress), frequent repositioning, and keeping the skin dry and clean from urine and stool. Scheduled urinary voidings are preferable to Foley catheters, which increase risk for urinary tract infection. In order to remove devitalized tissue, debridement is recommended for stages II, III, and IV ulcers. Hydrocolloid gels are recommended for stages II and III ulcers. Neither of these interventions would be indicated for this patient’s stage I ulcer. All pressure ulcers eventually become colonized with bacteria. Local wound care is the first management of these infections. Topical antibiotics are reasonable if the ulcer is unimproved after 2 weeks of local wound care. Intravenous antibiotics are reserved for patients with cellulitis, sepsis, or underlying osteomyelitis.