Bedsore short case with model viva answer

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Bedsore / Pressure Injury: Short Case With Model Viva Answers

Case presentation

“This is a 68-year-old bedridden male with stroke, admitted for 2 weeks. He has a wound over the sacral region for 5 days. On examination, there is a 4 × 3 cm ulcer over the sacrum with full-thickness skin loss, visible subcutaneous fat, granulation tissue, and no exposed bone, tendon, or muscle. There is no slough obscuring the base. Hence, this is a sacral pressure injury, Stage 3.”

Model viva questions and answers

1. What is a bedsore?

A bedsore, also called a pressure ulcer, decubitus ulcer, or preferably pressure injury, is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, caused by prolonged pressure, often combined with shear.

It develops when sustained pressure exceeds capillary perfusion pressure, causing ischemia, tissue hypoxia, necrosis, and ulceration.
Schwartz's Principles of Surgery, 11th ed., pressure sores section.

2. What are common sites?

Common sites are bony prominences:

Sacrum
Heel
Greater trochanter
Ischial tuberosity
Malleoli
Occiput
Elbow
Fibular head

In a supine patient, the sacrum, heels, occiput, and elbows are particularly vulnerable.
Bailey & Love's Short Practice of Surgery, 28th ed., p. 56.

3. What are the risk factors?

Extrinsic factors

Prolonged pressure
Shearing force
Friction
Moisture, especially urinary or fecal incontinence

Intrinsic factors

Immobility or paralysis
Old age
Malnutrition, especially protein-calorie deficiency
Sensory loss, such as spinal cord injury or neuropathy
Reduced level of consciousness
Anemia, dehydration, poor perfusion, diabetes, and severe systemic illness

Textbook of Family Medicine, 9th ed., pressure-ulcer risk factors section.

4. Describe the staging of pressure injuries.

Stage	Description
Stage 1	Intact skin with non-blanchable erythema over a localized area, usually a bony prominence.
Stage 2	Partial-thickness skin loss with exposed dermis. It may appear as a shallow ulcer or intact/ruptured blister.
Stage 3	Full-thickness skin loss. Subcutaneous fat and granulation tissue may be visible, but bone, tendon, and muscle are not exposed. Undermining or tunnelling may occur.
Stage 4	Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, cartilage, or bone.
Unstageable	Full-thickness loss, but the depth cannot be determined because the base is covered by slough or eschar.
Deep-tissue pressure injury	Persistent non-blanchable deep red, maroon, or purple discoloration, with or without a blood-filled blister, indicating underlying tissue damage.

The Washington Manual of Medical Therapeutics, pressure-injury staging section.
Bailey & Love's Short Practice of Surgery, 28th ed., p. 56.

5. How will you examine and document a bedsore?

I will document:

Site and number of ulcers
Stage of the ulcer
Size: length × width × depth in cm
Wound bed: granulation, slough, eschar, necrosis
Edges: undermining or tunnelling
Discharge: amount, color, and odor
Surrounding skin: erythema, maceration, cellulitis
Pain and tenderness
Evidence of systemic infection: fever, tachycardia
General status: nutrition, hydration, mobility, continence, sensory deficit, diabetes, anemia, and vascular status.

6. What investigations will you do?

Most pressure injuries are diagnosed clinically. Investigations are directed at associated illness and suspected complications:

CBC: anemia, leukocytosis
Blood glucose and HbA1c
Serum electrolytes and renal function
Nutritional assessment, including weight loss and dietary intake
Wound culture only if there are clinical signs of infection
Blood culture if sepsis is suspected
X-ray or MRI if osteomyelitis is suspected, especially in a deep sacral ulcer with exposed bone or persistent infection

7. How will you manage this patient?

Management has five principles:

A. Relieve pressure

Reposition regularly, usually at least every 2 hours for bedbound patients, individualized to the patient and support surface.
Off-load the heels completely using heel-protection devices or pillows under the calves.
Use a pressure-redistributing mattress or cushion.
Avoid dragging the patient during transfer, because this causes friction and shear.
Keep head-end elevation as low as clinically feasible to reduce sacral shear.

B. Treat the wound

Clean with normal saline.
Measure and document the wound at regular intervals.
Select an appropriate moisture-balancing dressing, for example foam or hydrocolloid dressing depending on exudate and wound condition.
Debride devitalized tissue if indicated, using sharp/surgical, autolytic, enzymatic, or mechanical techniques.
Do not debride stable, dry heel eschar unless there is infection, drainage, or instability.

C. Treat infection only when present

Look for cellulitis, purulent discharge, foul odor with clinical deterioration, fever, or sepsis.
Give systemic antibiotics for cellulitis, sepsis, or osteomyelitis, guided by culture where possible.
Routine antibiotics for every colonized ulcer are not indicated.

D. Optimize the patient

Correct dehydration, anemia, hyperglycemia, and underlying medical problems.
Give adequate calories and high-protein nutrition.
Obtain dietitian input if malnutrition or poor oral intake is present.
Control pain, especially before dressing changes and repositioning.
Manage incontinence and protect perineal skin from moisture.

E. Consider surgery

Surgical debridement or flap coverage may be required for selected deep Stage 3 or Stage 4 ulcers that fail conservative management, provided infection, nutrition, pressure relief, and comorbidities are adequately addressed first. Surgery is not first-line treatment.
Bailey & Love's Short Practice of Surgery, 28th ed., p. 56.
The Washington Manual of Medical Therapeutics, pressure-ulcer treatment section.

8. How will you prevent bedsores?

Prevention is the most important management.

Identify at-risk patients early using clinical judgment supported by tools such as the Braden, Norton, or Waterlow score.
Inspect skin daily, particularly over bony prominences.
Reposition regularly.
Use pressure-redistributing surfaces.
Keep skin clean, dry, and moisturized.
Promptly manage urinary or fecal incontinence.
Avoid massage over reddened bony prominences.
Ensure adequate protein, calorie, and fluid intake.
Encourage early mobilization and physiotherapy where feasible.
Educate caregivers and nursing staff.

Bailey & Love's Short Practice of Surgery, 28th ed., p. 56.

One-minute final summary for viva

“This patient has a sacral Stage 3 pressure injury due to prolonged immobilization. Pressure injury results from sustained pressure, shear, friction, and moisture, especially in malnourished or neurologically impaired patients. Management consists of pressure off-loading and regular repositioning, wound assessment and suitable dressing, debridement when indicated, treatment of proven infection, nutritional and medical optimization, and prevention of recurrence. Deep non-healing ulcers may require surgical debridement or flap cover.”

A recent Cochrane review found that nutritional interventions remain an active evidence area, but nutrition should be individualized and should not replace pressure relief and local wound care (Cochrane review, PMID 38345088). The current International Pressure Injury Guideline is being released in topic-based sections.

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