Ulcers

Pressure Ulcers
Pressure ulcers consist of local damage to the skin and
underlying tissue caused by compression between a bony
prominence and an external surface.7 Pressure ulcers are
classified along a four-grade scale (Table 14-2). They derive
from factors such as:

CLASSIFICATION OF
PRESSURE ULCERS
BY GRADE*
Grade 1—Non-blanchable erythema of intact skin.
Discoloration, warmth, induration, or hardness of skin may
also be used as indicators, particularly in people with darker
skin
Grade 2—Partial-thickness skin loss, involving epidermis,
dermis, or both. The ulcer is superficial and presents
clinically as an abrasion or blister
Grade 3—Full-thickness skin loss involving damage to or
necrosis of subcutaneous tissue that may extend down to,
but not through, underlying fascia
Grade 4—Extensive destruction, tissue necrosis or damage to
muscle, bone, or supporting structures, with or without
full-thickness skin loss

*As defined by the European Pressure Ulcer Advisory Panel and National
Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of
pressure ulcers: Quick reference guide. Washington, DC: National Pressure
Ulcer Advisory Panel.

Sensory deficits in individuals who cannot detect local

persistent pressure and who neglect to reposition
themselves
• Debility or paralysis so repositioning is not possible
• Medications that reduce tissue blood flow such as sedatives,
analgesics, and other medication
• Malnutrition that increases extent and severity
Facility-based caregivers have reporting requirements
for such ulcers under the Centers for Medicare and Medicaid
Services (CMS).
Interventions include the following:
• Assess and document risk factors in the individual and
environment including observations on caregiver’s
ability and how safe discharge can be done.
• Assess surfaces for softness, such as wheelchairs, prosthetics,
or bed coverings that you see.
• Assess nutritional and metabolic status by including
serum albumin and other testing.
• Patients with ulcers tend to have allergies to certain
dressings and topical medications, which should be considered
prior to wound care.
• CMS reporting means that facility records should reveal
ulcer size and location on admission.
• Assess the wound for infection, drainage, contaminants,
perspiration, and other contributing factors.
• Remove any drainage devices such as packing and
examine wound depth and condition.
• Surgical debridement may be needed, especially for
extensive grade 3 or 4 ulcers. Wounds cannot be staged
with an eschar present.

Aside from local care, patient may require higher care

level for ulcers that are infected, worsening, or new.
• Surgical consult may be indicated.
• Discharge teaching should include how pressure is being
relieved on pressure points, including the ulcer.
Consider osteomyelitis when any of the following is present: ulcer
down by the bone, fevers, high white blood cell count, or high
sedimentation rate.

Venous Ulcers
Venous ulcers are defined as local damage to the skin and
underlying tissue of the leg caused by chronic venous insufficiency,
age, and limited mobility. Symptoms include
aching, heaviness, itching, swelling, and skin breakdown.
Most can be managed by compression bandaging.6
Therapeutic interventions include the following:
• Leg elevation.
• Improve mobility.
• Improve nutrition.
• Surgery in selected cases. In the United States, venous
surgery is becoming more common not only as a last
resort in treating varicose veins, but also as an option
from the beginning.
• Dress with simple low adherence dressings under multilayer
compression bandage.
• Four-layer compression bandaging.
• Compression treatment heals ulcers at 12 to 15
weeks, and high compression is significantly better
than low compression.
• Applying these bandages takes some expertise and
referral should be made to someone skilled in
this area.
Diabetic Foot Ulcers
Diabetic foot ulcers occur from neuropathy that affects
more than half of diabetics and cause loss of the sensations
of temperature and pain from trauma. Diabetics are prone
to infection from reduced white cell responses. Most
cellulitis and fasciitis occurs from these ulcers. Osteomyelitis
is common and commonly requires amputation if it does
not heal.7
Therapeutic interventions include:
• Identification of new necrotic tissue or unhealthy tissue
for debridement.
• Documentation of the degree of neuropathy and mechanism
of trauma, if any.
• Antibiotics and close observation or admission for
infected wounds.
• Appropriate wound care, proper footwear, instruction to
patient or caregiver in foot assessment, and return
instructions for early infection in noninfected ulcers.

Bites
All bites from human beings or animals introduce bacteria
into the wound, which predisposes it to infection. These
wounds are considered tetanus-prone. Patients may require
prophylaxis for viral infections such as hepatitis or rabies as
well. Most clinicians elect to immediately close bites on the
face but not those on the hand. Hand wounds are closed
after 3 to 5 days or are packed and left open. Bites to the
torso, arms, and legs are managed in a variety of ways to
minimize infection and scarring. All puncture wounds from
bites are closed by secondary intention.
For all bites, therapeutic interventions include:
• Document the circumstances surrounding the bite, the
source of the bite, signs of infection, number of bites,
and the wound type, location, and depth.
• Assess for damage to underlying bone, muscle, tendons,
and nerves.
• Irrigate and debride wounds to minimize bacterial
contamination.5
Dog Bites
Dog bites are grouped roughly into two categories: provoked
and unprovoked. Provoked bites are incurred while
petting, teasing, or reaching for the dog or entering the
animal’s territory. Unprovoked attacks occur without
warning or provocation and are more likely to be associated
with rabies.19 Actual tissue damage from a dog bite depends
on the size and general state of the animal.19 The wound
may consist of multiple punctures, caused by the animal’s
teeth, or major tissue loss (avulsion) can result if flesh is
torn away from underlying structures. Significant crush
injuries occur if the animal bites down on a limb.
The dog bite infection rate for patients not receiving
antibiotics is 6% to 16%.12 The most common pathogens in
the animal’s saliva include Staphylococcus aureus and Pasteurella
multocida.2 Prophylaxis with amoxicillin/clavulanate
potassium (Augmentin) is recommended.
If evidence of infection is present, culture the wound
and begin antibiotic therapy. Progressive infection and
sepsis warrant intravenous antibiotics, hospital admission,
and (in some cases) operative debridement.

Cat Bites
Cats have long, slender fangs that cause puncture wounds
rather than lacerations, Cat bites show signs of infection
within 12 hours, and need treatment for P. multocida. The
antibiotic of choice for these infections is penicillin. Prophylaxis
with amoxicillin/clavulanate potassium (Augmentin)
is recommended, especially for bites on the hand.
Wounds are left open unless they are located on the face.12
Rabies Prophylaxis
Rabies is introduced into bites from an infected animal.
Theoretically, any mammal can be a carrier of rabies.
Common carriers are bats, raccoons, foxes, and wild dogs.
Herbivores, such as rodents, also can transmit the disease,
although this is unlikely. Local animal control offices can
provide information about rabies carriers in the area.
Bites from dogs that have been vaccinated, or from any
animal that can be observed for 2 weeks, usually do not
require rabies prophylaxis. If the animal dies within the
2-week observation period, the brain is autopsied to look
for signs of rabies infection. This allows prompt prophylaxis
for the victim if disease is detected.
Rabies has a minimum incubation period of 2 weeks in
which the virus migrates along the nerves to the brain.
Consequently, extremity bites have a longer incubation
than face or head wounds. Rabies prophylaxis must be
administered before symptoms begin. The disease is fatal in
human beings.
• Off-load pressure with total contact casting, removable
cast walkers, and ambulatory braces, splints, half shoes,
and sandals.
• Good glycemic control results in faster healing and
reduced infection. Assess home glucose monitoring
and HgA1c level along with plan to have patient
optimize medication through his or her supervising
clinician.
Bites
All bites from human beings or animals introduce bacteria
into the wound, which predisposes it to infection. These
wounds are considered tetanus-prone. Patients may require
prophylaxis for viral infections such as hepatitis or rabies as
well. Most clinicians elect to immediately close bites on the
face but not those on the hand. Hand wounds are closed
after 3 to 5 days or are packed and left open. Bites to the
torso, arms, and legs are managed in a variety of ways to
minimize infection and scarring. All puncture wounds from
bites are closed by secondary intention.
For all bites, therapeutic interventions include:
• Document the circumstances surrounding the bite, the
source of the bite, signs of infection, number of bites,
and the wound type, location, and depth.
• Assess for damage to underlying bone, muscle, tendons,
and nerves.
• Irrigate and debride wounds to minimize bacterial
contamination.5
Dog Bites
Dog bites are grouped roughly into two categories: provoked
and unprovoked. Provoked bites are incurred while
petting, teasing, or reaching for the dog or entering the
animal’s territory. Unprovoked attacks occur without
warning or provocation and are more likely to be associated
with rabies.19 Actual tissue damage from a dog bite depends
on the size and general state of the animal.19 The wound
may consist of multiple punctures, caused by the animal’s
teeth, or major tissue loss (avulsion) can result if flesh is
torn away from underlying structures. Significant crush
injuries occur if the animal bites down on a limb.
The dog bite infection rate for patients not receiving
antibiotics is 6% to 16%.12 The most common pathogens in
the animal’s saliva include Staphylococcus aureus and Pasteurella
multocida.2 Prophylaxis with amoxicillin/clavulanate
potassium (Augmentin) is recommended.
If evidence of infection is present, culture the wound
and begin antibiotic therapy. Progressive infection and
sepsis warrant intravenous antibiotics, hospital admission,
and (in some cases) operative debridement.
TABLE 14-3 CDC AND PREVENTION
RECOMMENDATIONS
FOR RABIES
PROPHYLAXIS
Passive Immunity
• Rabies immune globulin (RIG)
• 20 units/kg
• Give half the dose intramuscularly and inject the other
half locally into the wound.
• Inject in the deltoid for adults and in the anterolateral
thigh in children.
Active Immunity
• Human diploid cell vaccine (HDCV)
• Give 1 mL intramuscularly on days 0, 3, 7, 14, and 28.
• Give 1 mL intramuscularly only on days 0 and 3 if the
patient had been immunized preexposure.
Data from Denke, N. J. (2010). Wound management. In P. K. Howard &
R. A. Steinmann (Eds.), Sheehy’s emergency nursing: Principles and
practice (6th ed., pp. 111–126). St. Louis, MO: Mosby.

Rabies prophylaxis is initiated routinely if a bat, wild

animal, or domestic animal that cannot be observed adequately
caused the wound. Table 14-3 provides current
guidelines for rabies prophylaxis.
Many states require that all animal bites be reported.
Refer to local guidelines to determine requirements in your
practice area.20

Bites from dogs that have been vaccinated, or from any

animal that can be observed for 2 weeks, usually do not
require rabies prophylaxis. If the animal dies within the
2-week observation period, the brain is autopsied to look
for signs of rabies infection. This allows prompt prophylaxis
for the victim if disease is detected.
Rabies has a minimum incubation period of 2 weeks in
which the virus migrates along the nerves to the brain.
Consequently, extremity bites have a longer incubation
than face or head wounds. Rabies prophylaxis must be
administered before symptoms begin. The disease is fatal in
human beings.

TABLE 14-3 CDC AND PREVENTION

RECOMMENDATIONS
FOR RABIES
PROPHYLAXIS
Passive Immunity
• Rabies immune globulin (RIG)
• 20 units/kg
• Give half the dose intramuscularly and inject the other
half locally into the wound.
• Inject in the deltoid for adults and in the anterolateral
thigh in children.
Active Immunity
• Human diploid cell vaccine (HDCV)
• Give 1 mL intramuscularly on days 0, 3, 7, 14, and 28.
• Give 1 mL intramuscularly only on days 0 and 3 if the
patient had been immunized preexposure.
Data from Denke, N. J. (2010). Wound management. In P. K. Howard &
R. A. Steinmann (Eds.), Sheehy’s emergency nursing: Principles and
practice (6th ed., pp. 111–126). St. Louis, MO: Mosby.

Procedural Sedation
Lauren Wheatley McCauley