it's been a long time since i've seen a stage iv decubitus. i've seen them over the coccyx, the greater trochanter area of the hips, and on the heels of the feet. just to be fair, i've also seen a couple of decubitus on the ears, but they had only gotten to a stage iii. i've also seen huge stage iv craters on the butts of paraplegics that required extensive surgical repair (skin flaps). over the years i've seen several paraplegics who were very belligerent and just absolutely refused to stay turned while in bed and insisted on being up in their wheelchairs for hours and hours on end. yes, it's a pretty sour kind of rotting smell that these kinds of wounds have. it usually permeates the room. we used to be able to get a room freshener from central supply that was like a large plug-in. it had a large solid air-wick deodorizer tube in it that fit into a little machine we sat on the floor, plugged in and blew the air freshener into the room continuously. it helps until you actually have to do a dressing change.
before some of you go jumping the gun and blaming the ltc for this ulcer, you need to understand that there are severe penalties for any nursing home that allows this to happen to one of their patients. all decubitus in the state of ohio have to be reported to the state and their progress monitored. i imagine this is probably done in a lot of other states as well. the don of a facility should know the specific regulations on this. anyway, the nursing home has to show that they are actively attempting to treat and heal the decubitus through a multi-discipline approach. that means dietary has to also be involved in the care of these wounds. there are situations where a patient's general state of health is so bad that their bodies are unable to heal these despite treatment and turning. because of this reporting requirement, we went over a newly admitted resident with a magnifying glass (i'm being metaphorical to emphasize the significance of this) looking for any skin breakdown or open wounds that someone forgot to tell us about. we occasionally got patients from their own homes who came in with the worst ulcers. some of these patients are immobile in their homes and for some reason or another end up in the hospital and then the nursing home, or go directly from home to the nursing home. it is unlikely, although not impossible, that a person was admitted to the acute hospital with no skin breakdown, but came out with a stage iv decubitus. most patients aren't in the acute hospital long enough for this serious a decubitus to happen. today, most of the acute hospitals get patients discharged and out as soon as possible due to the way the prospective payment system is set up. i'm sure there are instances of it happening, but i doubt it happens as frequently as you would think.
this is one very good reason why you should always do a thorough assessment of a patient, especially on admission. this is particularly true of all elderly, immobile or bed-bound patients. we should do skin checks on them--period. after awhile you become very tactful at making skin inspections and still maintaining a patients dignity.
by the way, the nip/tuck episode entitled "mama boone" which is about a morbidly obese lady who is stuck to the chair she has been sitting in for 3 years because her skin has grown in and fused with the chair is being re-broadcast on friday evening, november 18th. in the episode, the plastic surgeons work to separate the skin on her legs from the fabric of the chair in order to attempt to get her out of the chair. it is based on a true incident.