A prospective pilot study of atypical pressure ulcer presentation in a skilled geriatric nursing unit

Local (extrinsic) and systemic (intrinsic) risk factors for the development of pressure ulcers over bony prominences such as the sacrum, coccyx, ischium, gluteal area, and leg area (heels) have been extensively studied and documented. Several case studies have described (but little is known about) pressure ulcers in atypical anatomical locations. A descriptive pilot study was conducted to document the occurrence, cause, prevention, assessment, and treatment of pressure ulcers in atypical anatomical locations. Thirty-two (32) patients (53% female) in a skilled geriatric long-term care nursing department participated in the 6-month study. All patients were immobile (100%) and most had feeding (91%) and neurological problems (80%). All care was provided by a multidisciplinary team. Twenty-six (26) new ulcers developed during the course of the study. Of those, 13 (40% occurrence rate) were in an atypical location and were found to have an uncommon pathogenesis. A review of the data showed that six (6) pressure ulcers were associated with medical devices (tubes, catheters, and tapes for affixation), four (4) with increased spasticity, and three (3) with bone deformity. The ulcers associated with medical devices (iatrogenic) were observed at the site of insertion or device placement; ulcers associated with spasticity or bone deformity were noted at the site of increased muscle tone and pressure. Using a multidisciplinary specialty and team approach, underlying risk factors were addressed as part of the wound care protocol. Although the study duration was short and the sample size small, these results suggest that the incidence of atypical pressure ulcers in immobile patients with multiple comorbidities may be underreported and underestimated. Additional studies are needed to increase awareness and understanding about the scope of this problem and to develop targeted approaches to prevention and care.