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& x003E; .

Maureen Haggerty

L. Lee Culvert