Bedsores

Definition
Demographics
Description
Diagnosis/Preparation
Alternatives
Prevention

Definition

Bedsores are also called decubitus ulcers, pressure ulcers, or pressure sores. They begin as tender, inflamed patches that develop when a person’s weight rests against a hard surface, exerting pressure on the skin and soft tissue over bony parts of the body. For example, bedsores are common when skin covering a weight-bearing part of the body, such as a knee or hip, is pressed between a bone and a bed, chair, another body part, splint, or other hard object. This is most likely to happen when the person is confined to a bed or wheelchair for long periods and is relatively immobile. Usually, mobile individuals receive pain signals from the compressed part of the body and will automatically move to relieve the pressure, thus bedsores do not usually develop in people with normal mobility and mental alertness. However, people compromised through spinal cord injury, acute illness, heavy sedation, unconsciousness, or diminished mental functioning, may not receive signals to move, and as a result of the constant pressure, tissue damage often progresses to bedsores in these individuals.

Demographics

Each year, about 1.8 million people in the United States develop bedsores at a treatment cost of $1.3 billion. In 2004, 17,000 lawsuits resulted from treatment related to bedsores. Pressure sores are most common in elderly patients; records show that 70% of all bedsores occur in people over age 70. People who are neurologically impaired, such as those with spinal injuries or paralysis, have a 5–8% chance annually of developing a bedsore. This translates into a 25–85% lifetime risk. Complications from pressure sores are the direct cause of death in about 8% of nursing home residents.

The National Pressure Ulcer Advisory Panel (NPUAP) estimates that bedsores afflict:

• 9-13% of all hospital patients
• up to 23.9% of nursing home residents
• at least 60% of elderly individuals with hip and femur (thigh bone) fractures

Description

Bedsores range from mild inflammation to ulceration (breakdown of tissue) and deep wounds that involve muscle and bone. This painful condition usually starts with shiny red skin that quickly blisters and

KEY TERMS

Debridement— Cutting away tissue from a wound.

Gangrene— Tissue death resulting from lack of nutrients and oxygen.

Inflammation (inflamed)— Pain, heat, redness, swelling, and reduced function of tissue, often leading to infection.

Ischemia— Localized anemia, or lack of blood flow and oxygen delivery to a specific area, such as the skin.

Soft tissue— Layers of cells that form the skin.

Ulceration— Death of tissue cells in a specific area, such as skin.

deteriorates into open sores. These sores leave the body open to bacterial and fungal contamination and can harbor life-threatening infection. Bedsores are not contagious or cancerous, although the most serious complication of chronic bedsores is the development of malignant degeneration, which is a type of cancer.

Bedsores develop because of pressure that cuts off the flow of blood and oxygen to tissue. Constant pressure pinches off capillaries, the tiny blood vessels that deliver oxygen and nutrients to the skin. If the skin is deprived of oxygen and essential nutrients (a condition known as ischemia) for as little as one hour, tissue cells can die (anoxia) and bedsores can form. Even the slightest rubbing or friction between a hard surface and skin stretched over bones can cause minor pressure ulcers. They can also develop when a patient stretches or bends blood vessels by slipping into a different position in a bed or chair.

Urine, feces, or other moisture increase the risk of skin infection, so people who are incontinent (unable to control bladder or bowel movements), as well as those who are immobile or have nerve damage that prevents them from feeling pain, have a high risk of developing bedsores.

Bedsores are difficult to successfully treat and recurrence is common. People who have experienced bedsores have a 90% chance of developing them again, even when the bedsores have been successfully treated. While mild pressure sores themselves can usually be cured, complications from pressure ulcers are the direct cause of death in about 8% of paraplegic individuals. Pressure sores can be slow to heal, particularly when the patient’s overall physical status may be weakened. Without proper treatment, bedsores can lead to:

• gangrene (tissue death)
• osteomyelitis (infection of the bone beneath the bedsore)
• sepsis (a poisoning of tissue or the whole body from bacterial infection)
• other localized or systemic infections that slow the healing process, increase the cost of treatment, lengthen hospital or nursing home stays, or cause death

About 93% of bedsores develop below the waist. Bedsores are most apt to develop on bony parts of the body, including:

• ankles
• heels
• hips and buttocks
• knees
• lower back
• shoulder blades
• back of the head

Although impaired mobility is a leading factor in the development of pressure sores, the risk is also increased by illnesses and conditions that weaken muscle and soft tissue or that affect blood circulation and the delivery of oxygen to body tissue, leaving skin thinner and more vulnerable to breakdown and subsequent infection. These conditions include:

• atherosclerosis (hardening of arteries) that restricts blood flow
• diabetes
• diminished sensation or lack of feeling or inability to feel pain
• heart problems
• incontinence
• malnutrition
• obesity
• paralysis
• poor circulation
• infection
• prolonged bed rest, especially in unsanitary conditions or with wet or wrinkled sheets
• spinal cord injury

Diagnosis/Preparation

Physical examination, medical history, and patient and caregiver observations are the basis of diagnosis. Special attention must be paid to physical or mental problems, such as an underlying disease, incontinence, or confusion that could complicate a patient’s recovery. Nutritional status and smoking history should also be noted.

The National Pressure Ulcer Advisory Panel recommends classification of bedsores in four stages of ulceration based primarily on the depth of a sore at the time of examination. This helps to create standardized descriptive language and encourages effective communication of medical personnel caring for patients with bedsores. The NPUAP advises that not all bedsores follow the stages directly from I to IV. The four most widely accepted stages are described as:

• Stage I: intact skin with redness (erythema) and sometimes with warmth. In people with dark skin, rather than appearing red, the area may appear blue or purple or sometimes lighter than the rest of the skin.
• Stage II: tissue damage has occurred. The outermost layer of skin has been lost and the sore shows abrasion, swelling, and possible blistering or peeling.
• Stage III: all skin has been lost; damage has reached the tissue below the skin. The bedsore appears as a deep open wound (crater).
• Stage IV: extensive skin loss with damage to the underlying tissue that extends into muscle, bone, tendon, or joint. These bedsores can be fatal.

In addition to observing the depth of the wound, the caregiver should note the presence or absence of wound drainage, foul odors, or any debris in the wound, such as pieces of dead skin tissue or other material. Any condition that could likely contaminate the wound and cause infection, such as the presence of urine or feces from incontinence, should be noted as well.

A physician should be notified whenever a person:

• will be bedridden or immobilized for an extended time period.
• is very weak or unable to move.
• develops redness (inflammation) and warmth or peeling on any area of skin.

Immediate medical attention is required whenever:

• skin turns black or becomes inflamed, tender, swollen, or warm to the touch.
• the patient develops a fever during treatment.
• a bedsore contains pus or has a foul-smelling discharge.

Prompt medical attention can prevent surface pressure sores from deepening into more serious infections. The first step is always to reduce or eliminate the pressure that is causing bedsores. For minor bedsores, stages I and II, treatment involves relieving pressure, keeping the wound clean and moist, and keeping the area around the ulcer clean and dry. This is often accomplished with saline (salt water) washes and the use of sterile medicated gauze dressings that both absorb the wound drainage and fight infection-causing bacteria. Antiseptics, harsh soaps, and other skin cleansers can damage new tissue and should be avoided. Only sterile saline solution should be used to cleanse bedsores whenever fresh non-stick dressings are applied.

The patient’s doctor may prescribe infection-fighting antibiotics, special dressings or drying agents, and/or lotions or ointments to be applied to the wound in a thin film three or four times a day. Warm whirlpool treatments are sometimes recommended for sores on the arm, hand, foot, or leg.

Typically, with the removal or reduction of pressure in conjunction with proper treatment and attention to the patient’s general health, including good nutrition, bedsores should begin to heal two to four weeks after treatment begins.

A 2006 peer-reviewed clinical trial of 89 residents in 23 nursing homes reinforced the concept that good nutrition will aid in treatment. The trial reported that patients receiving the protein supplement, Pro-Stat, along with standard pressure sore care, showed a 96% improvement in healing over patients receiving a placebo (supplement with no protein) and standard care.

Surgical options are often considered for non-healing wounds. When deep wounds are not responding well to standard medical procedures, consultation with a plastic surgeon may be needed to determine if reconstructive surgery is the best possible treatment. In a procedure called debriding, a scalpel may be used to remove dead tissue or other debris from stage III and IV wounds. A surgical procedure called urinary (or fecal) diversion may also be used with incontinent patients to divert the flow of urinary or fecal material. This keeps the wound clean and encourages wound healing. Reconstruction involves the complete removal of the ulcerated area and surrounding damaged tissue (excision), debriding the bone, and reducing the amount of bacteria in the area with vigorous flushing (lavage) with saline solution. The surgical wound is then drained for a period of days until it is clear that no infection is present and that healing has begun. Plastic surgery may follow to close the wound with a flap (skin from another part of the body), providing a new tissue surface over the bone. For surgery to succeed, infection must not be present. High rates of complications tend to occur after reconstructive surgery. These include bleeding under the skin (hematoma), wound infection, and the recurrence of pressure

sores. Infection in deep wounds can progress to life-threatening systemic infection. Amputation may be required when a wound will not heal or when reconstructive surgery is not an option for a particular patient.

Alternatives

Zinc and vitamins A, C, E, and B complex provide necessary nutrients for the skin and help it to repair injuries and stay healthy. Large doses of vitamins or minerals should not be used without a doctor’s approval.

A poultice made of equal parts of powdered slippery elm (Ulmus fulva), marsh mallow (Althaea officinalis), and echinacea blended with a small amount of hot water can relieve minor inflammation. An infection-fighting rinse of two drops of essential tea tree oil (Melaleuca) to every 8 oz (0.23 g) of water can also be administered. An herbal tea made from calendula (Calendula officinalis) is also an effective antiseptic and wound-healing agent. Calendula cream can also be used.

Contrasting hot and cold compresses applied to the bedsore site can increase circulation to the area and help flush out waste products, speeding the healing process. The temperatures should be extreme (very hot and ice cold), yet tolerable to the skin. Hot compresses should be applied for three minutes, followed by 30 seconds of cold compress application, repeating the cycle three times. The cycle should always end with a cold compress.

Prevention

It is easier to prevent bedsores from developing than to cure them once they have occurred. Good nutrition plays an important role in keeping the skin intact and in promoting wound healing; the diet of bedridden individuals should not be ignored. All patients recovering from illness or surgery or confined to a bed or wheelchair long term should be inspected at least daily, but preferably more often. They should be bathed or should shower every day using warm water and mild soap, and should avoid cold or dry air. Bedridden patients who are either mentally unaware or physically unable to turn themselves must be repositioned regularly by caregivers at minimum once every two hours while awake and preferably more frequently. People who use a wheelchair should be encouraged to shift their weight every 10-15 minutes or be repositioned by caregivers at least once an hour.

It is important to lift, rather than to drag, a person being repositioned. Bony parts of the body should not be massaged. Even slight friction can remove the weakened top layer of skin and damage blood vessels beneath it. Sensitive body parts can be protected by:

• sheepskin pads
• special cushions placed on top of a mattress
• a water-filled mattress
• a variable-pressure mattress with individually inflatable sections to redistribute pressure

Pillows or foam wedges can prevent the ankles of a bedridden patient from rubbing on each other, and pillows placed under the legs from mid-calf to ankle can raise the heels off the bed. Raising the head of the bed slightly and briefly can provide relief, but raising the head of the bed more than 30° can cause the patient to slide, thereby causing damage to skin and tiny blood vessels.

A person who uses a wheelchair should be encouraged to sit up as straight as possible. Pillows behind the head and between the legs can help prevent bedsores, as can a special cushion placed on the chair seat. Donut-shaped cushions should not be used because they restrict blood flow and cause tissues to swell.

Special support surfaces are manufactured and readily available for care in medical facilities or at home, including air-filled mattresses and cushions, low-air loss beds, and air-fluidized beds. These devices give adequate support while reducing pressure on vulnerable skin. They have been shown to exert less pressure on the skin of compromised patients than do regular mattresses. Patients using these devices and beds must still be repositioned every two hours.

Resources

ORGANIZATIONS

National Pressure Ulcer Advisory Panel. 12100 Sunset Hills Road, Suite 130, Reston, VA 20190. (703)464-4849. http://www.npuap.org (accessed March 7, 2008).

OTHER

“Bedsores.” Moon Dragon’s Health and Wellness. August 23, 2006. [cited January 1, 2008]. http://www.moondragon.org/health/disorders/bedsores.html (accessed March 7, 2008).

“Bedsores (Pressure sores).” Mayo Clinic. March 19, 2007. [cited January 1, 2008]. http://www.mayoclinic.com/health/bedsores/DS00570 (accessed March 7, 2008).

“Pressure Sores.” American Academy of Family Physicians. December 2006/ [cited January 1, 2008]. http://familydoctor.org/online/famdocen/home/seniors/endoflife/039.html (accessed March 7, 2008).

“Pressure Ulcers.” American Medical Association. August 23, 2006. [cited January 1, 2008]. http://jama.ama-assn.org/cgi/reprint/296/8/1020.pdf (accessed March 7, 2008).

Maureen Haggerty

L. Lee Culvert

Tish Davidson, AM

Betamethasone seeCorticosteroids

Bicarbonate test seeElectrolyte tests

Bile duct stone removal seeEndoscopic retrograde cholangiopancreatography

Bedsores

Definition

Bedsores, also called decubitus ulcers, pressure ulcers, or pressure sores, begin as tender, inflamed patches that develop when a person's weight rests against a hard surface, exerting pressure on the skin and soft tissue over bony parts of the body. For example, skin covering a weight-bearing part of the body, such as a knee or hip, is pressed between a bone and a bed, chair, another body part, splint, or other hard object. This is most likely to happen when the person is confined to a bed or wheelchair for long periods of time and is relatively immobile. Usually, mobile individuals, when either conscious or unconscious, will receive nerve signals from the compressed part of the body and will automatically move to relieve the pressure. Pressure sores do not usually develop in people with normal mobility and mental alertness. However, people compromised through acute illness, heavy sedation, unconsciousness, or diminished mental functioning, may not receive signals to move, and as a result of the constant pressure, tissue damage may progress to bedsores in these individuals.

Demographics

Each year, about one million people in the United States develop bedsores at a treatment cost of $1 billion. Pressure sores are most often found in elderly patients; records show that two thirds of all bedsores occur in people over age 70. People who are neurologically impaired, such as those with spinal injuries or paralysis, are also at high risk. Pressure sores have been noted as a direct cause of death in about 8% of paraplegics.

In 1992, the Federal Agency for Health Care Policy and Research reported that bedsores afflict:

• 10% of all hospital patients
• 25% of nursing home residents
• 60% of quadriplegics

Description

Bedsores range from mild inflammation to ulceration (breakdown of tissue) and deep wounds that involve muscle and bone. This painful condition usually starts with shiny red skin that quickly blisters and deteriorates into open sores. These sores become a target for bacterial contamination and will often harbor life-threatening infection. Bedsores are not contagious or cancerous, although the most serious complication of chronic bedsores is the development of malignant degeneration, which is a type of cancer.

Bedsores develop as a result of pressure that cuts off the flow of blood and oxygen to tissue. Constant pressure pinches off capillaries, the tiny blood vessels that deliver oxygen and nutrients to the skin. If the skin is deprived of essential oxygen and nutrients (a condition known as ischemia) for even as little as an hour, tissue cells can die (anoxia) and bedsores can form. Even the slightest rubbing, called shear, or friction between a hard surface and skin stretched over bones, can cause minor pressure ulcers. They can also develop when a patient stretches or bends blood vessels by slipping into a different position in a bed or chair.

Since urine, feces, or other moisture increases the risk of skin infection, people who suffer from incontinence, as well as immobility, have a greater than average risk of developing bedsores.

Unfortunately, people who have been successfully treated for bedsores have a 90% chance of developing them again. While the pressure sores themselves can usually be cured, about 60,000 deaths per year are attributed to complications caused by bedsores. They can be slow to heal, particularly when the patient's overall status may be weakened. Without proper treatment, bedsores can lead to:

• gangrene (tissue death)
• osteomyelitis (infection of the bone beneath the bedsore)
• sepsis (a poisoning of tissue or the whole body from bacterial infection)
• other localized or systemic infections that slow the healing process, increase the cost of treatment, lengthen hospital or nursing home stays, or cause death

Bedsores are most apt to develop on bony parts of the body, including:

• ankles
• back of the head
• heels
• hips
• knees
• lower back
• shoulder blades
• spine

Although impaired mobility is a leading factor in the development of pressure sores, the risk is also increased by illnesses and conditions that weaken muscle and soft tissue, or that affect blood circulation and the delivery of oxygen to body tissue, leaving skin thinner and more vulnerable to breakdown and subsequent infection. These conditions include:

• atherosclerosis (hardening of arteries) that restricts blood flow
• diabetes
• diminished sensation or lack of feeling, unable to feel pain
• heart problems
• incontinence (inability to control bladder or bowel movements)
• malnutrition
• obesity
• paralysis
• poor circulation
• infection
• prolonged bed rest, especially in unsanitary conditions or with wet or wrinkled sheets
• spinal cord injury

Diagnosis/Preparation

Physical examination , medical history, and patient and caregiver observations are the basis of diagnosis. Special attention must be paid to physical or mental problems, such as an underlying disease, incontinence, or confusion that could complicate a patient's recovery. Nutritional status and smoking history should also be noted.

The National Pressure Ulcer Advisory Panel (NPUAP) recommends classification of bedsores in four stages of ulceration based primarily on the depth of a sore at the time of examination. This helps standardize the language and encourages effective communication of medical personnel caring for patients with bedsores. The NPUAP advises that not all bedsores follow the stages directly from I to IV. The four most widely accepted stages are described as:

• Stage I: intact skin with redness (erythema) and sometimes with warmth.
• Stage II: partial-thickness loss of skin, an abrasion, swelling, and possible blistering or peeling of skin.
• Stage III: full-thickness loss of skin, open wound (crater), and possible exposed under layer.
• Stage IV: full-thickness loss of skin and underlying tissue, extends into muscle, bone, tendon, or joint. Possible bone destruction, dislocations, or pathologic fractures (not caused by injury).

In addition to observing the depth of the wound, the presence or absence of wound drainage and foul odors, or any debris in the wound, such as pieces of dead skin tissue or other material, should also be noted. Any condition that could likely contaminate the wound and cause infection, such as the presence of urine or feces from incontinence, should be noted as well.

A doctor should be notified whenever a person:

• will be bedridden or immobilized for an extended time period
• is very weak or unable to move
• develops redness (inflammation) and warmth or peeling on any area of skin

Immediate medical attention is required whenever:

• skin turns black or becomes inflamed, tender, swollen, or warm to the touch
• the patient develops a fever during treatment
• a bedsore contains pus or has a foul-smelling discharge

Prompt medical attention can prevent surface pressure sores from deepening into more serious infections. The first step is always to reduce or eliminate the pressure that is causing bedsores. For minor bedsores, stages I and II, treatment involves relieving pressure, keeping the wound clean and moist, and keeping the area around the ulcer clean and dry. This is often accomplished with saline washes and the use of sterile medicated gauze dressings that both absorb the wound drainage and fight infection-causing bacteria. Antiseptics , harsh soaps, and other skin cleansers can damage new tissue and should be avoided. Only saline solution should be used to cleanse bedsores whenever fresh non-stick dressings are applied.

The patient's doctor may prescribe infection-fighting antibiotics , special dressings or drying agents, and/or lotions or ointments to be applied to the wound in a thin film three or four times a day. Warm whirlpool treatments are sometimes recommended for sores on the arm, hand, foot, or leg.

Typically, with the removal or reduction of pressure in conjunction with proper treatment and attention to the patient's general health, including good nutrition, bedsores should begin to heal two to four weeks after treatment begins.

Surgical options are often considered for non-healing wounds. When deep wounds are not responding well to standard medical procedures, consultation with a plastic surgeon may be needed to determine if reconstructive surgery is the best possible treatment. In a procedure called debriding, a scalpel may be used to remove dead tissue or other debris from Stage III and IV wounds. A surgical procedure called urinary (or fecal) diversion may also be used with incontinent patients to divert the flow of urinary or fecal material—this keeps the wound clean and encourages wound healing. Reconstruction involves the complete removal of the ulcerated area and surrounding damaged tissue (excision), debriding the bone, and reducing the amount of bacteria in the area with vigorous flushing (lavage) with saline solution. The surgical wound is then drained for a period of days until it is clear that no infection is present and that healing has begun. Plastic surgery may follow to close the wound with a flap (skin from another part of the body), providing a new tissue surface over the bone. For surgery to succeed, infection must not be present. Complications can occur after reconstructive surgery; these include bleeding under the skin (hematoma), wound infection, and the recurrence of pressure sores. Infection in deep wounds can progress to life-threatening systemic infection. Amputation may be required when a wound will not heal or when reconstructive surgery is not an option for a particular patient.

Alternatives

Zinc and vitamins A, C, E, and B complex provide necessary nutrients for the skin and help it to repair injuries and stay healthy. Large doses of vitamins or minerals should not be used without a doctor's approval.

A poultice made of equal parts of powdered slippery elm (Ulmus fulva ), marsh mallow (Althaea officinalis ), and echinacea blended with a small amount of hot water can relieve minor inflammation. An infection-fighting rinse of two drops of essential tea tree oil (Melaleuca) to every 8 oz (0.23 g) of water can also be administered. An herbal tea made from calendula (Calendula officinalis ) is also an effective antiseptic and wound healing agent. Calendula cream can also be used.

Contrasting hot and cold compresses applied to the bedsore site can increase circulation to the area and help flush out waste products, speeding the healing process. The temperatures should be extreme (very hot and ice cold), yet tolerable to the skin. Hot compresses should be applied for three minutes, followed by 30 seconds of cold compress application, repeating the cycle three times. The cycle should always end with a cold compress.

Prevention

It is usually possible to prevent bedsores from developing or worsening. In 1989, the NPUAP set a goal that pressure sores be reduced by 50% by 2000. Because of the varying ways in which the number of cases were recorded during this timeframe, the NPUAP is finding it difficult to analyze accurate incident accounts. However even with the diversity of recording methods and the difficulties in comparing data, small group data indicates that progress has been made with the standardization of guidelines and care.

All patients recovering from illness or surgery or confined to a bed or wheelchair long-term should be inspected regularly; they should be bathed or should shower every day using warm water and mild soap; and patients should avoid cold or dry air. Bedridden patients who are either mentally unaware or physically unable to turn themselves, must be repositioned regularly by caregivers at least once every two hours while awake. People who use a wheelchair should be encouraged to shift their weight every 10 or 15 minutes, or be repositioned by caregivers at least once an hour. It is important to lift, rather than to drag, a person being repositioned. Bony parts of the body should not be massaged. Even slight friction can remove the weakened top layer of skin and damage blood vessels beneath it.

If the patient is bedridden, sensitive body parts can be protected by:

• sheepskin pads
• special cushions placed on top of a mattress
• a water-filled mattress
• a variable-pressure mattress with individually inflatable sections to redistribute pressure

Pillows or foam wedges can prevent a bedridden patient's ankles from irritating each other, and pillows placed under the legs from mid-calf to ankle can raise the heels off the bed. Raising the head of the bed slightly and briefly can provide relief, but raising the head of the bed more than 30 degrees can cause the patient to slide, thereby causing damage to skin and tiny blood vessels.

A person who uses a wheelchair should be encouraged to sit up as straight as possible. Pillows behind the head and between the legs can help prevent bedsores, as can a special cushion placed on the chair seat. Donutshaped cushions should not be used because they restrict blood flow and cause tissues to swell.

Special support surfaces are manufactured and readily available for care in medical facilities or at home, including: air-filled mattresses and cushions, low-air loss beds, and air-fluidized beds. These devices give adequate support while reducing pressure on vulnerable skin. They have been shown to exert less pressure on the skin of compromised patients than do regular mattresses. Patients using these devices and beds must still be repositioned every two hours.

Resources

organizations

International Association of Enterstomal Therapy. 27241 La Paz Road, Suite 121, Laguna Niguel, CA 92656. (714) 476-0268.

National Pressure Ulcer Advisory Panel. 12100 Sunset Hills Road, Suite 130, Reston, VA 20190. (703) 464-4849. <http://www.npuap.org>.

other

"Bed Sores." American Health and Herbs Ministry. March 15, 1998 [cited April 9, 2003]. <http://www.healthherbs.com>.
"Pressure Ulcers." American Medical Association. January 8, 2003 [cited April 9, 2003]. <http://www.nlm.nih.gov/medlineplus>. "Preventing Bedsores." Mayo Clinic. June 5, 2001 [cited February 20, 2003]. <http://www.mayoclinic.com>.

"Preventing Pressure Ulcers." Atlanta Health Pages Library. [cited April 9, 2003]. <http://www.healthpages.org/AHP/LIBRARY/HLTHTOP/MISC/bedsore.htm>.

Maureen Haggerty

L. Lee Culvert

PRESSURE ULCERS

Skin ulcerations caused by pressure and/or shearing stress are known under a variety of names, including decubitus ulcers, pressure ulcers, pressure sores, and bedsores. They are caused by impaired blood flow (perfusion) through the affected area, which reduces tissue oxygenation. This process is termed ischemia and results in partial or total tissue death. It occurs when there is concentrated external pressure on part of the body for a period of time. This commonly occurs in an area with a bony prominence, such as the knees, hips, or elbows, but it can also occur in a number of other areas if the underlying tissue of fat and muscle is thinned. The effect is enhanced if the skin vessels have been previously damaged by intermittent pressure.

Shearing occurs when there is a sliding movement on the skin surface, producing partial or complete disruption of the underlying tissues. Minor shearing forces, short of actual disruption, occur quite frequently and produce ischemia due to impairment of the blood flow. Any factor (e.g., bedsheets, moist skin) that increases frictional resistance of the skin surface will increase the tendency to shear.

Maceration results when the skin surface is moist and occluded for a prolonged time. The outer part of the skin becomes whitish and soggy, and bacteria and other organisms can then proliferate. Such organisms invade when a slight abrasion occurs, and the resulting infection can lead to skin breakdown. Even minute foreign materials on the skin surface, such as dried bread crumbs or other debris, can cause local ischemia and thus promote breakdown.

Care must be taken to distinguish harmless colonization of bacteria from the pathological state of infection. The presence of inflammation (redness, heat, pain, and swelling) characterizes infection.

General factors that can increase the risk of pressure ulcers include poor nutrition, debilitating illness, clouding of consciousness causing immobility, and impending death. Conditions that predispose a person to bedsores include urinary or fecal incontinence, insensitive skin, peripheral vascular disease through arteriosclerosis or diabetes, and being underweight or overweight. The incidence of this condition in hospitals provides clues as to standards of care. It has been recorded variously as being between 2.7 percent and 29.5 percent, with a prevalence of 3 to 5 percent. When a pressure sore occurs in the elderly or immobile in a nursing home, there is a fourfold increase in the risk of death.

A number of classifications of ulceration have been used, but that of the National Pressure Ulcer Advisory Panel (NPUAP) is now generally favored (see Table 1).

The economics of bedsores is also important. It is difficult to estimate the cost of ulcer management, as settings vary from acute-care institutions to chronic-care nursing homes. For acute care, one estimate put the cost at between $5,000 and $40,000 per patient per year. The cost is significantly less in chronic care institutions.

To prevent bedsores, an optimal nutritional state must be achieved. In particular, a positive protein balance and adequate Vitamin C, iron, and zinc levels are required. Debilitated elderly persons, the mentally disabled, and those with dietary deficiency due to social circumstance are all at risk. For those at risk, the daily nursing routine must include inspection at least once daily. The bedridden should be turned at least every two hours, with good nursing techniques used to avoid friction and shear. Skin moisture and soiling must be minimized.

There are a number of ways in which pressure can be redistributed from bony prominences and other predisposed sites. Pillows or foam wedges are used to separate limbs. Doughnuts are not used, as they can increase pressure. Wheelchair cushions should be made of foam, viscoelastic foam, gel, or fluid flotation. Similarly, mattresses of the air pressure, water, air-fluidized, or air-support types are recommended. Team consultation, combining doctors, attending nurses, physiotherapists, occupational therapists, and equipment suppliers can be most helpful in planning the various stages of management (see Table 2).

The affected areas should be dressed using surgical gauze in combination with certain other materials. Films are thin, transparent, semipermeable, and nonabsorbent. They can be left in place for one or two days. Hydrocolloids are adherent, impermeable to gas, and are absorbent. They conform to the area on which they are used and can be left for a few days on deeper wounds. Foams are moist and absorbent, and they require a dressing to hold them in place. Alginates are used for deep cavities and sinuses. They are very absorptive and need a secondary dressing. Other agents used to treat pressure ulcers include growth factors, hyperbaric oxygen, skin grafts, and skin substitutes. In general, healing times are one to two weeks for Stage II and six weeks to three months for Stages III and IV.

J. Barrie Ross

See also Gerontological Nursing; Skin; Surgery in Older People.

BIBLIOGRAPHY

Bar, C. A., and Pathy, M. S. J. "Pressure Sores." In Principles and Practice of Geriatric Medicine, 3d ed. Edited by M. S. J. Pathy. Chichester: John Wiley & Sons, 1998. Pages 1375–1394.

Bennett, G. C. J. "Pressure Sores—Aetiology and Prevalence." In Textbook of Geriatric Medicine and Gerontology, 4th ed. Edited by J. C. Brocklehurst, R. C. Tallis, and H. M. Fillit. Edinburgh: Churchill, 1992. Pages 922–938.

Kanj, L. F.; Wilking, S.; Van, B.; and Phillips, T. J. "Pressure Ulcers." Journal of the American Academy of Dermatology 38 (1998): 517–536.

PREVENTIVE MEDICINE

See Periodic health examination

Bedsores

Definition

Bedsores are also called decubitus ulcers, pressure ulcers, or pressure sores. These tender or inflamed patches develop when skin covering a weight-bearing part of the body is squeezed between bone and another body part, or a bed, chair, splint, or other hard object.

Description

Each year, about one million people in the United States develop bedsores ranging from mild inflammation to deep wounds that involve muscle and bone. This often painful condition usually starts with shiny red skin that quickly blisters and deteriorates into open sores that can harbor life-threatening infection.

Bedsores are not cancerous or contagious. They are most likely to occur in people who must use wheelchairs or who are confined to bed. In 1992, the federal Agency for Health Care Policy and Research reported that bedsores afflict:

• 10% of hospital patients
• 25% of nursing home residents
• 60% of quadriplegics

The Agency also noted that 65% of elderly people hospitalized with broken hips develop bedsores and that doctors fees for treatment of bedsores amounted to $2,900 per person.

Bedsores are most apt to develop on the:

• ankles
• back of the head
• heels
• hips
• knees
• lower back
• shoulder blades
• spine

People over the age of 60 are more likely than younger people to develop bedsores. Risk is also increased by:

• atherosclerosis (hardening of arteries)
• diabetes or other conditions that make skin more susceptible to infection
• diminished sensation or lack of feeling

• heart problems
• incontinence (inability to control bladder or bowel movements)
• malnutrition
• obesity
• paralysis or immobility
• poor circulation
• prolonged bed rest, especially in unsanitary conditions or with wet or wrinkled sheets
• spinal cord injury

Causes and symptoms

Bedsores most often develop when constant pressure pinches tiny blood vessels that deliver oxygen and nutrients to the skin. When skin is deprived of oxygen and nutrients for as little as an hour, areas of tissue can die and bedsores can form.

Slight rubbing or friction against the skin can cause minor pressure ulcers. They can also develop when a patient stretches or bends blood vessels by slipping into a different position in a bed or chair.

Urine, feces, or other moisture increases the risk of skin infection, and people who are unable to move or recognize internal cues to shift position have a greater than average risk of developing bedsores.

Other risk factors include:

• malnutrition
• anemia (lack of red blood cells)
• diuse atrophy (muscle loss or weakness from lack of use)
• infection

Diagnosis

Bedsores usually follow six stages:

• redness of skin
• redness, swelling, and possible peeling of outer layer of skin
• dead skin, draining wound, and exposed layer of fat
• tissue death through skin and fat, to muscle
• inner fat and muscle death
• destruction of bone, bone, infection, fracture, and blood infection

Treatment

Prompt medical attention can prevent surface pressure sores from deepening into more serious infections. For mild bedsores, treatment involves relieving pressure, keeping the wound clean and moist, and keeping the area around the ulcer clean and dry. Antiseptics, harsh soaps, and other skin cleansers can damage new tissue, so a saline solution should be used to cleanse the wound whenever a fresh non-stick dressing is applied.

The patient's doctor may prescribe infection-fighting antibiotics, special dressings or drying agents, or lotions or ointments to be applied to the wound in a thin film three or four times a day. Warm whirlpool treatments are sometimes recommended for sores on the arm, hand, foot, or leg.

In a procedure called debriding, a scalpel may be used to remove dead tissue or other debris from the wound. Deep, ulcerated sores that don't respond to other therapy may require skin grafts or plastic surgery.

A doctor should be notified whenever a person:

• will be bedridden or immobilized for an extended time
• is very weak or unable to move
• develops bedsores

Immediate medical attention is required whenever:

• skin turns black or becomes inflamed, tender, swollen, or warm to the touch.
• the patient develops a fever during treatment.
• the sore contains pus or has a foul-smelling discharge.

With proper treatment, bedsores should begin to heal two to four weeks after treatment begins.

Alternative treatment

Zinc and vitamins A, C, E, and B complex help skin repair injuries and stay healthy, but large doses of vitamins or minerals should never be used without a doctor's approval.

A poultice made of equal parts of powdered slippery elm (Ulmus fulva ), marsh mallow (Althaea officinalis ), and echinacea (Echinacea spp.) blended with a small amount of hot water can relieve minor inflammation. An infection-fighting rinse can be made by diluting two drops of essential tea tree oil (Melaleuca spp.) in eight ounces of water. An herbal tea made from the calendula (Calendula officinalis ) can act as an antiseptic and wound healing agent. Calendula cream can also be used.

Contrasting hot and cold local applications can increase circulation to the area and help flush out waste products, speeding the healing process. The temperatures should be extreme (hot hot and ice cold), yet tolerable to the skin. Hot compresses should be applied for three minutes, followed by 30 seconds of cold compress application, repeating the cycle three times. The cycle should always end with the cold compress.

Prevention

It is usually possible to prevent bedsores from developing or worsening. The patient should be inspected regularly; should bathe or shower every day, using warm water and mild soap; and should avoid cold or dry air. A bedridden patient should be repositioned at least once every two hours while awake. A person who uses a wheelchair should shift his weight every 10 or 15 minutes, or be helped to reposition himself at least once an hour. It is important to lift, rather than drag, a person being repositioned. Bony parts of the body should not be massaged. Even slight friction can remove the top layer of skin and damage blood vessels beneath it.

If the patient is bedridden, sensitive body parts can be protected by:

• sheepskin pads
• special cushions placed on top of a mattress
• a water-filled mattress
• a variable-pressure mattress whose sections can be individually inflated or deflated to redistribute pressure.

Pillows or foam wedges can prevent a bedridden patient's ankles from irritating each other, and pillows placed under the legs from mid-calf to ankle can raise the heels off the bed. Raising the head of the bed slightly and briefly can provide relief, but raising the head of the bed more than 30 degrees can cause the patient to slide, thereby causing damage to skin and tiny blood vessels.

A person who uses a wheelchair should be encouraged to sit up as straight as possible. Pillows behind the head and between the legs can help prevent bedsores, as can a special cushion placed on the chair seat. Donut-shaped cushions should not be used because they restrict blood flow and cause tissues to swell.

Prognosis

Bedsores can usually be cured, but about 60,000 deaths a year are attributed to complications caused by bedsores. Bedsores can be slow to heal. Without proper treatment, they can lead to:

• gangrene (tissue death)
• osteomyelitis (infection of the bone beneath the bedsore)
• sepsis (tissue-destroying bacterial infection)
• other localized or systemic infections that slow the healing process, increase the cost of treatment, lengthen hospital or nursing home stays, or cause death

Resources

ORGANIZATIONS

International Association of Enterstomal Therapy. 27241 La Paz Road, Suite 121, Laguna Niguel, CA 92656. (714) 476-0268.

National Pressure Ulcer Advisory Panel. SUNY at Buffalo, Beck Hall, 3435 Main St., Buffalo, NY 14214. (716) 881-3558. 〈http://www.npuap.org〉.

Bedsores

Definition

Bedsores are the result of inflammation and damage caused by irritation to the skin and inhibited blood flow. The condition occurs when skin is rubbed against a bed, chair, cast, or other hard object for an extended period of time. Bedsores can range from mild inflammation to deep wounds that involve muscle and bone. Infections can be a serious complication to the condition.

Description

Bedsores are also called decubitus ulcers, pressure ulcers, or pressure sores. They often start out with shiny red skin that becomes itchy or painful, then quickly blisters and deteriorates into open sores. Once there is a break in the skin, there is a strong possibility of the sore becoming infected, causing further medical problems. Bedsores are most apt to develop over the bony prominences of the ankles, the hip bones, the lower back, the shoulders, the spinal column, the buttocks, and the heels of the feet. Bedsores are most likely to occur in people who must use wheelchairs or who are confined to bed.

Bedsores are medically categorized by stages:

• Stage I: The skin reddens, but it remains unbroken.
• Stage II: Redness, swelling, and blisters develop. There is possibly peeling of the outer layer of the skin.
• Stage III: A shallow open wound develops on the skin.
• Stage IV: The sore deepens, spreading through layers of skin and fat down to muscle tissue.
• Stage V: Muscle tissue is broken down.
• Stage VI: The underlying bone is exposed, and there is danger of severe damage and infection.

Causes & symptoms

Bedsores most often happen when the most superficial blood vessels are pressed against the skin and squeezed shut, closing off the flow of blood. If the supply of blood to an area of skin is cut off for more than an hour, the tissue will began to die due to lack of oxygen and nutrients. Ordinarily, the layer of fat under the bony areas of the skin helps keep the blood vessels from being compressed in this way. Also, people have a normal impulse to change positions frequently when they are sitting or lying down, so the blood supply is usually not kept from any area of the skin for very long. Bedsores are most likely to occur in people who have lost the protective fat layer or whose movement impulse is hindered.

Friction or rubbing from poorly fitted shoes or clothing and wrinkled bedding often cause a sore to develop. Constant exposure to the moisture of urine, feces, and perspiration may also cause the skin to deteriorate. In such cases there is an increased the risk of skin infection as well as sores.

Risk factors for bedsores:

• older than 60 years of age
• heart disease
• diabetes
• diminished tactile sensation
• incontinence
• malnutrition
• obesity
• paralysis or immobility
• poor circulation
• prolonged bed rest
• spinal cord injury
• anemia
• disuse atrophy

Diagnosis

Physical examination of the skin, medical history, and patient and caregiver observations are the basis of diagnosis. Any sign of reddening of the skin will be closely monitored.

Treatment

Contrasting hot and cold local applications can increase circulation to problem areas and help flush out waste products, speeding the healing process. Hot compresses should be applied for three minutes, followed by 30 seconds of cold compress application, repeating the cycle three times. The cycle should always end with the cold compress. In addition, zinc and vitamins A, C, E, and B-complex should be taken to help maintain healthy skin and repair injuries.

Herbal remedies

A poultice can be made of equal parts of powdered slippery elm , Ulmus fulva ; marsh mallow root, Althaea officinalis ; and Echinacea spp. The herbs should be blended together with a small amount of hot water and applied to the skin three or four times per day to relieve inflammation. Poultices used on broken skin or infected areas should never be reused.

An infection-fighting rinse can be made by diluting two drops of essential tea tree oil , Melaleuca spp., in eight ounces of water. This should be used to bathe the wound when bandages are changed.

An herbal tea made from Calendula officinalis can be used as an antiseptic wash and a wound healing agent. Calendula cream can also be applied to the affected area.

A poultice made from goldenseal , Hydrastis canadensis, and water or goldenseal ointment can be applied to areas of inflammation several times per day to heal the skin and prevent infection.

Allopathic treatment

A healthcare provider should be consulted whenever a person develops bedsores. An emergency situation may be indicated if sores become tender, swollen, or warm to the touch, if the patient develops a fever , or if the sore has pus or a foul-smelling discharge.

For mild bedsores, treatment basically involves relieving pressure on the area and keeping the skin clean and dry. When the skin is broken, a non-stick covering may be used. A saline solution is often used to clean the wound site whenever a fresh bandage is applied. Disinfectants are applied if the site is infected. The doctor may also prescribe antibiotics, special dressings or drying agents, and ointments to be applied to the wound. Heat

lamps are used quite successfully to dry out and heal the sores. Warm whirlpool treatments are sometimes also recommended for sores on the arm, hand, foot, or leg.

In a procedure called debridement, a scalpel may be used to remove dead tissue or other debris from the wound. Deep sores that don't respond to other therapy may require skin grafts or plastic surgery. If there is a major infection, oral antibiotics may be given. If a bone infection, called osteomyelitis, develops or infection spreads through the bloodstream, aggressive treatment with antibiotics over the course of several weeks may be required.

Expected results

With proper treatment, bedsores should begin to heal two to four weeks after treatment begins. Left untreated, however, gangrene , osteomyelitis, or a systemic infection may develop. In the United States, about 60,000 deaths a year are attributable to complications caused by bedsores.

Prevention

Prompt medical attention can prevent pressure sores from deepening into more serious infections. People whose movement or sense of touch is limited by disability and disease should be monitored to insure that the skin remains clean, dry, healthy. A bedridden patient should be repositioned at least once every two hours while awake. A person who uses a wheelchair should remember to shift the body's position often or they should be helped to reposition the body at least once an hour. To avoid injury, it is important to lift, rather than drag, a person being repositioned. Wheelchair users should sit up as straight as possible, with pillows behind the head and between the legs if needed. Donut-shaped seat cushions should not be used because they may restrict blood flow.

Even slight friction can remove the top layer of skin and damage the blood vessels beneath it. Pillows or foam wedges can be used to keep the ankles from rubbing together and irritating each other; pillows placed under the lower legs can raise the heels off the bed. To minimize pressure sores, there should be adequate padding in beds, chairs, and wheelchairs. Those who are bed-ridden can be protected by using sheepskin pads, specialized cushions, and mattresses filled with air or water. In addition, a 1997 study indicates that topical use of essential fatty acids can help the skin stay healthy.

Resources

BOOKS

Berkow, MD, Robert, editor-in-chief, et al The Merck Manual of Medical Information, Home Edition. New York: Pocket Books, 1997.

The Editors of Time-Life Books The Medical Advisor: The Complete Guide to Alternative and Conventional Treatments Virginia: Time-Life, Inc., 1996.

PERIODICALS

Declair, V. Ostomy Wound Management 43, no. 5 (1997): 48-52.

ORGANIZATIONS

International Association of Enterstomal Therapy, 27241 La Paz Road, Suite 121, Laguna Niguel, CA 92656

National Pressure Ulcer Advisory Panel, SUNY at Buffalo, Beck Hall, 3435 Main Street, Buffalo, NY 14214 <http://www.npuap.org.>

Patience Paradox