Decubitus Ulcer

Definition

A decubitus ulcer (pressure injury, pressure ulcer, bedsore) is localized damage to skin and underlying soft tissue from prolonged pressure, friction, or shear over bony prominences such as the sacrum, heels, trochanters, and elbows.

Staging (NPIAP)

• Stage 1: Intact skin with non-blanchable redness.
• Stage 2: Partial-thickness skin loss involving epidermis/dermis. Shallow open ulcer or blister.
• Stage 3: Full-thickness skin loss, visible fat.
• Stage 4: Full-thickness loss with exposed bone, tendon, or muscle.
• Unstageable: Full-thickness loss obscured by slough/eschar.
• Deep Tissue Injury: Purple/maroon discoloration of intact skin.

Prevention (Most Important)

Turn every 2 hours, use pressure-reducing mattresses, float heels, maintain HOB less than 30° when possible (reduces shear), keep skin clean and dry, use moisture barriers for incontinence, optimize nutrition (protein, calories, vitamin C, zinc), daily skin assessment, and use Braden Scale risk stratification.

NCLEX Relevance

Turn every 2 hours is a classic intervention. Protein is critical for healing.