Decubitus Ulcers

Pathophysiology

External pressure: When pressure exceeds normal capillary filling pressure for >2 hours, oxygen deprivation leads to irreversible tissue damage
Shearing forces and friction: Sliding tissue layers stretch blood vessels, causing injury and thrombosis
Moisture: Sweat, urine, or feces weaken cell walls and change the skin's protective pH
Staging: Stage I (persistent non-blanchable redness) through Stage IV (full-thickness destruction involving muscle, bone, or supporting structures)
"Tip of the iceberg" — extensive underlying damage can exist beneath a small surface lesion
Long-term inflammation is a risk factor for aggressive squamous cell carcinoma

Persistent non-blanchable redness on bony prominences (Stage I)
Blisters, abrasions, shallow or deep craters (Stages II-III)
Full-thickness tissue destruction involving muscle and bone (Stage IV)
Skin feels cooler or warmer than surrounding areas. Boggy, mushy, or firm texture
Most common sites: sacrum, heels, elbows, ankles, ischial tuberosities
Bluish or purple discoloration indicates deeper tissue damage

Non-blanchable redness on a bony prominence: Early pressure injury — do not massage the area
"Tip of the iceberg": Surface lesion may mask extensive underlying damage extending to bone
Necrotic debris or foul odor: Risk of septicemia — medical emergency
Impaired sensation: Highest risk factor — patients who cannot feel pressure do not shift weight
Clients unable to independently reposition: Primary risk population

Strictly contraindicated locally once tissue damage begins or an ulcer is imminent — infection risk and tissue fragility
Prevention only: Massage may be used as a preventive tool to promote blood flow BEFORE skin breaks down, but only if the client has good sensation and resilient skin
Do not manipulate reddened skin: Can worsen tissue breakdown
Many vulnerable patients lack adequate sensation and skin resilience for even preventive massage
Position changes: Encourage repositioning every 2 hours for bedridden clients
Untreated necrotic debris can lead to septicemia — life-threatening systemic infection

4-stage classification: non-blanchable redness (I) to full-thickness loss involving muscle/bone (IV)
"Tip of the iceberg": extensive underlying damage beneath a small surface lesion
2-hour window: irreversible tissue damage begins after 2 hours of constant pressure
Most common sites: sacrum, heels, elbows, ankles, ischial tuberosities
Impaired sensation is the highest risk factor
Long-term inflammation is a risk factor for squamous cell carcinoma

Decubitus ulcers are ischemic lesions caused by unrelieved pressure exceeding 2 hours on bony prominences
The "tip of the iceberg" principle: surface lesions may mask extensive underlying tissue damage
Massage is strictly contraindicated locally once tissue damage begins. Appropriate only as prevention
Impaired sensation is the highest risk factor — patients do not unconsciously shift weight
Staging ranges from non-blanchable redness (Stage I) to full-thickness destruction involving muscle and bone (Stage IV)