A long standing bed ridden patient presented with the following condition over the heel region.What would be the grade of this condition?
The patient in question is suffering from Pressure Ulcer.
BED SORE/ PRESSURE SORE
- These can be defined as tissue necrosis with ulceration due to prolonged pressure. Less preferable terms are bed sores, pressure ulcers and decubitus ulcers.
- If external pressure exceeds the capillary occlusive pressure (over 30 mmHg), blood flow to the skin ceases leading to tissue anoxia,necrosis and ulceration .
- Prevention is obviously the best treatment with good skin care, special pressure dispersion cushions or foams, the use of low air loss and air-fluidised beds and urinary or faecal diversion in selected cases. The bed-bound patient should be turned at least every 2 hours.
Pressure sore frequency in descending order
- Greater trochanter
- Malleolus (lateral then medial)
Staging of pressure sores
- Stage 1 Non-blanchable erythema without a breach in the epidermis
- Stage 2 Partial-thickness skin loss involving the epidermis and dermis
- Stage 3 Full-thickness skin loss extending into the subcutaneous tissue but not through underlying fascia
- Stage 4 Full-thickness skin loss through fascia with extensive tissue destruction, maybe involving muscle, bone, tendon or joint.
- For stage 1 and 2 pressure injuries, wound care is usually conservative (ie, nonoperative)
- Pressure reduction – Repositioning and use of support surfaces
- Wound management – Débridement, cleansing agents, dressings, and antimicrobials
- For stage 3 and 4 lesions, surgical intervention (eg, flap reconstruction) may be required, though some of these lesions must be treated conservatively because of coexisting medical problems 
- Approximately 70%-90% of pressure injuries are superficial and heal by second intention