A 74-year-old woman with Alzheimer disease is evaluated for a sacral ulcer. She has become increasingly dependent on others for day-to-day activities and has been bed-bound for the past year. The patient developed a sacral pressure ulcer a few months ago, and it has progressively enlarged with excessive drainage. Her other medical problems include hypertension, osteoarthritis, and urinary incontinence. She lives with her sister and gets care from a 24-hour caregiver and a visiting nurse.
Temperature is 36.7 C (98 F), blood pressure is 150/80 mm Hg, and pulse is 68/min. The patient is confused but has no focal neurologic deficits. She has a 3- to 4-cm sacral ulcer with visible subcutaneous tissue, grayish slough, and foul-smelling drainage. There is no surrounding erythema or fluctuation.
Laboratory studies are as follows:

Which of the following is the best next step in managing this patient's pressure ulcer?

Question

A 74-year-old woman with Alzheimer disease is evaluated for a sacral ulcer.  She has become increasingly dependent on others for day-to-day activities and has been bed-bound for the past year.  The patient developed a sacral pressure ulcer a few months ago, and it has progressively enlarged with excessive drainage.  Her other medical problems include hypertension, osteoarthritis, and urinary incontinence.  She lives with her sister and gets care from a 24-hour caregiver and a visiting nurse.
Temperature is 36.7 C (98 F), blood pressure is 150/80 mm Hg, and pulse is 68/min.  The patient is confused but has no focal neurologic deficits.  She has a 3- to 4-cm sacral ulcer with visible subcutaneous tissue, grayish slough, and foul-smelling drainage.  There is no surrounding erythema or fluctuation.
Laboratory studies are as follows:

Which of the following is the best next step in managing this patient's pressure ulcer?

Quizplus · Accepted Answer

11ec193a_9791_43cf_853d_95f147ccde42_MD0002_00 This patient has a stage III pressure ulcer, defined as full-thickness skin loss with possible visible subcutaneous fat. Initial management of pressure ulcers includes local wound care, repositioning of the patient to relieve pressure, pain control, and nutritional support. Patients who do not improve with conservative therapy require evaluation for signs of infection (eg, erythema, purulent drainage, tenderness, fluctuance). Patients without signs of infection can be treated with a 2-week course of topical antibiotics. stage III pressure ulcer Patients with signs of local infection can be treated with topical antibiotics, whereas patients with cellulitis (eg, erythema, warmth, swelling over involved area) or sepsis/bacteremia require systemic antibiotics. All patients with signs of infection should undergo debridement. Surgical debridement removes necrotic tissue and accumulated debris, which helps to decrease bacterial load and stimulate wound epithelialization. This patient has necrotic tissue with signs of local infection (grayish slough, foul-smelling drainage) without cellulitis; therefore, she should receive debridement and topical antibiotics (Choice E). If there is no improvement, she should undergo tissue biopsy, MRI of the sacrum, and possibly bone biopsy to exclude osteomyelitis (Choice C). (Choice B) Pressure ulcers cause a chronic catabolic state and require adequate nutrition for proper wound healing. However, this patient first needs nutritional assessment (eg, protein/caloric intake, serum albumin and/or prealbumin) before considering enteral nutritional supplementation. (Choice D) Occlusive dressings may help with wound healing by preventing contamination and absorbing excess fluid to prevent wound maceration. However, they are usually done after debridement and control of local infection. Educational objective: Nonhealing pressure ulcers without signs of infection can be treated with topical antibiotics. Ulcers with signs of local infection can be treated with topical antibiotics and debridement. Ulcers complicated by cellulitis or sepsis/bacteremia require systemic antibiotics and debridement. __________ References: Management of pressure ulcers. (http://www.ncbi.nlm.nih.gov/pubmed/15487879)

A 74-Year-Old Woman with Alzheimer Disease Is Evaluated for a Sacral