BED SORES

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Bed sores, also known as pressure ulcers, pressure sores or decubitus ulcers are skin lesions which can be caused by friction, humidity, temperature, continence, medication, shearing forces, age and unrelieved pressure. Any part of the body may be affected; bony or cartilaginous areas, such as the elbows, knees, ankles and sacrum are most commonly affected. The sacrum is a triangular bone at the base of the spine and the upper and back part of the pelvic cavity (like a wedge between the two hip bones).

If discovered early, bed sores are treatable. However, they may sometimes be fatal. According to health authorities in the UK and USA, bed sores are the second iatrogenic cause of death, after adverse drug reactions. Iatrogenic cause of death means unexpected death caused by medical treatment – death caused by the action of a physician or a therapy the doctor prescribed.

In the 1950s, Doreen Norton (1922-2007), a British nurse, used research to demonstrate that the best treatment and prevention of bedsores was removing the pressure by turning the patient every two hours. Norton is seen as instrumental in changing nursing practices to effectively treat pressure ulcers, which was a major killer of hospital patients.

According to Medilexicon’s medical dictionary:
A decubitus ulcer is “a chronic ulcer that appears in pressure areas of skin overlying a bony prominence in debilitated patients confined to bed or otherwise immobilized, due to a circulatory defect.”

An acute decubitus ulcer is ” a severe form of bedsore, of neurotrophic origin, occurring in hemiplegia or paraplegia.” (Hemiplegia = paralysis on one side of the body. Paraplegia = paralysis of the lower part of the body, including limbs.
Pressure ulcers (bed sores) develop when the skin and the tissue below it becomes damaged. In severe cases the muscle and the bone may be damaged too. Pressure ulcers are much more common among patients who are unable to move because of paralysis, illness or old age. Sustained pressure can cut off circulation to vulnerable parts of the body, especially the skin of the buttocks, hips and heels – the affected tissue dies if it does not receive an adequate flow of blood.

According to the National Health Service (NHS), UK, it is estimated that between 4% and 10% of all hospitalized patients develop at least one pressure ulcer. Up to 70% of UK elderly patients with mobility problems develop bed sores.

Experts say that even with excellent medical and nursing care, bed sores can be hard to prevent, especially among vulnerable patients. Anyone, not only those living with paralysis, can develop bed sores – any person who cannot change position without help can develop bedsores. The bedsores can develop and progress rapidly and are frequently difficult to heal. Doctors say that with proper preventive measures the skin’s integrity can more easily be maintained, resulting in better healing of bedsores.
What are the risk factors for bed sores?
A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

Pressure ulcers are more common among:
•Patients who are immobilized because of injury, acute illness or sedation. Their immobile state does not have to occur for long for bed sores to develop.
•Individuals with long-term spinal cord injuries. Because the nerve damage is often permanent, compression of the skin and some tissues is constant; damaged or atrophied skin as well as poor circulation increases the risk of damage and lowers the chances of proper healing. Patients with long-term spinal cord injuries also have reduced sensation, so they often do not receive the body signals (pain, discomfort, etc) which would make them automatically change positions – i.e. patients do not feel a developing bed sore and lie on it, resulting in a rapidly-developing sore.
Patients who cannot move specific parts of their body unaided may have a greater risk of developing pressure ulcers if:
•They are elderly – elderly people have thinner skin, which is more vulnerable to damage from minor pressure. If a very elderly individual is underweight (often the case), there will be less padding around their bones. Another common problem among very elderly patients is poor nutrition, which may affect skin and blood vessel quality, resulting in less effective healing.

Experts say that even if a very elderly patient eats properly and enjoys good overall health, healing is much slower when compared to younger people.
•The patient resides in a nursing home – the incidence of bed sores in nursing homes is significantly higher than in hospital or at home (very elderly cared for at home). This could be due partly to the fact that those in nursing homes tend to be especially frail.
•Is in a coma – hospitalized patients who are in a coma are especially vulnerable to bed sores. The reasons are obvious; they cannot move unaided and do not respond to or acknowledge pain like other people do.
•Is not perceiving pain – some diseases, as well as most spinal cord injuries, can reduce or eliminate the patient’s sensation of pain. Somebody who does not feel pain does not take steps to relieve it, such as changing position or asking somebody to move him/her, and also may not know that a pressure ulcer is developing.
•Loses weight in hospital – people who are hospitalized often lose weight because of their condition, especially if they are unable to move. The loss of fat and muscle leaves the bones more exposed to damage.
•Is not eating properly – patients who are not eating properly, especially those whose diets are poor in protein, vitamin C and zinc have a higher risk of developing bed sores.
•Has incontinence (urinary or fecal) – if a patient urinates uncontrollably there will be areas of permanently moist skin, resulting in a greater risk of skin breakdown. Fecal incontinence raises the risk of bacteria causing skin problems and getting through cracks and wounds in the skin and causing serious systemic complications, such as gangrene, sepsis and other rapidly spreading infections.
•Has an illness or medical condition – patients with diabetes and vascular diseases that affect circulation may have problems with proper blood flow to certain tissues, resulting in a higher risk of tissue damage.
•Is a smoker – nicotine undermines circulation, while smoking reducing the amount of oxygen in blood; this has a negative effect on healing.
•Has lower mental awareness – if the patient is not fully mentally aware, perhaps because of a disease, injury or medication, they will not be able to take action to prevent or facilitate the healing of pressure ulcers.
What are the signs and symptoms of pressure ulcers?
A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

Parts of the body that are not covered by a high level of body fat and flesh (muscle) and are in direct contact with a supporting surface, such as a bed or wheelchair have the highest risk of developing pressure ulcers. Bedbound patients are most at risk of developing bed sores on their:
•Ankles
•Back of the head
•Breasts (female patients)
•Elbows
•Genitals (male patients)
•Heels
•Knees
•Rims of the ears
•Shoulder blades
•Shoulders
•Toes
Patients who use a wheelchair have a higher risk of developing pressure sores on their:
•Buttocks
•Tailbone
•Spine
•Shoulder blades
•Back of arms
•Back of legs
Grading the pressure ulcers
Pressure sores are classified into four possible stages, depending on their severity. The National Pressure Ulcer Advisory Panel, USA, defines each stage as follows:
•Stage I – starts as a persistent area of red skin, which may be itchy, painful and may also feel warm, spongy or firm when touched. Among people of African ancestry, and individuals with darker skin, the mark may seem to have a bluish/purplish cast; it may even look ashen or flaky. As soon as the pressure is relieved, the sore generally goes away rapidly.
•Stage II – skin loss has already taken place. This could be in the epidermis (the outer layer of skin), or the dermis (deeper down in the skin) – sometimes both. The pressure ulcer is at this point an open sore, similar to an abrasion or a blister. The surrounding tissue may appear red or purple.
•Stage III – there is now a deep wound, like a crater; the damage has gone below the skin. There is skin loss which occurs throughout the entire thickness of the skin. The underlying muscles and bone are not damaged.
•Stage IV – the most severe type of ulcer. Skin is severely damaged and there is tissue necrosis (surrounding tissue starts to die). Underlying muscles or bone (or both) may also be damaged. Tendons and joints may also be damaged. At this point there is a serious risk of developing a life-threatening infection.
What are the causes of pressure ulcers?
Healthy and mobile individuals make numerous postural adjustments throughout the day to prevent pressure sores from ever developing. These subtle movements we take for granted are not possible for patients who are paralyzed, injured, ill or very old and frail. For them, pressure ulcers are a constant risk.

Pressure ulcers, especially for immobilized individuals, are usually caused by:
•Continuous pressure – if there is pressure on the skin on one side, and bone on the other, the skin and underlying tissue may not receive an adequate blood supply. Oxygen and other key nutrients may be lacking, resulting in possible skin and tissue damage. Areas most susceptible are those which are not well padded with flesh (muscle) and fat; areas just over a bone, such as the coccyx (tailbone), shoulder blades, hips, heels, ankles and elbows. Some causes of circulation loss may seem unlikely, but they do exist, such as crumbs in the patient’s bed, wrinkles in the sheets and clothing, thick seams in pants (UK: trousers), a slightly tilting chair. Even sweating can moisten the skin and raise the risk of bed sores.
•Friction – for healthy and mobile people making bodily adjustments – shifting around – prevents the development of bed sores. However, for some patients, especially those with very thin and frail skin, as well as poor circulation, turning and moving may damage the skin, raising the risk of bed sores.
•Shear – if the skin moves one way while the underlying bone moves in the opposite direction, this is known as shear. If a patient slides down a bed or a chair, or raises the top half of a bed too much, there is a risk of shearing – cell walls and minute blood vessels may stretch and tear. The tailbone, especially if the skin is already very thin, is especially susceptible to bed sores from shear.
Diagnosing pressure ulcers and ulcer management
Diagnosis of a pressure ulcer is made by visual examination. Good diagnostic process, experts say, is to accurately assess the patient’s risk of developing bed sores. To do this, the medical team will assess the patient’s:
•State of health
•Mobility (how much, often and easily can the patient move).
•Posture – is there anything that may affect the patient’s posture.
•Signs or symptoms that may point to an infection.
•Mental health
•Mental state
•Personal history of pressure ulcers
•Continence – urinary or/and fecal
•Nutrition
•Blood circulation
To better assess the patient’s risk, the doctor may order urine and blood tests. Blood tests, apart from providing important data on the patient’s health, may also provide clues on how well he/she is eating. Urine tests may provide details on the state of the kidneys, or whether a urinary tract infection is present.

Self checking – if the patient is not in a hospital, care home, nursing home (any primary care setting), the doctor or nurse may teach them how to carry out regular daily checks for pressure ulcers. This will involve looking out for discoloration of the skin, and touching the skin for any unusual texture. A household member may help check parts of the body that are hard to look at, such as the back or buttocks – the patient might use a mirror. Any signs or symptoms of possible bed sores should be reported to a health care professional as soon as possible.

Removing a sample – if there is a wound that does not heal, even after treatment, or if the patient has chronic pressure ulcers, the doctor may take a small sample of tissue. This tissue is then cultured for unusual fungi or bacteria. Sometimes it is also checked for cancer.
What are the treatment options for pressure ulcers?
Treating pressure ulcers is not easy. If it is an open wound it most likely will not heal rapidly; even when healing does take place it may be patchy because the skin and other tissues have already been damaged. A multidisciplinary approach is required to deal with the many aspects of wound care. According to the National Health Service (NHS), UK, the MDT (multidisciplinary team) may consist of:
•A dietician
•A gastroenterologist (a digestive system doctor specialist)
•A neurosurgeon (a brain and nervous system specialist surgeon)
•An orthopedic surgeon (a bone and joints specialist surgeon)
•A physical therapist (UK: physiotherapist)
•A plastic surgeon
•A social worker
•A urologist (a urinary system specialist doctor)
•An incontinence advisor
•Nurses
The majority of Stage I and Stage II pressure ulcers will heal within a few weeks just with conservative measures. However, Stages III and IV wounds may require surgery.

Step 1 in treating any sore, regardless of its stage, is to remove the pressure that is causing it. This can be done by:
•The patient’s positions – the patient needs to be turned and repositioned regularly. If the individual is in a wheelchair this may mean changing positions every 15 minutes. A bedridden patient may require repositioning every couple of hours. Sheepskin or some type of padding over the wound may help reduce friction when the patient is repositioned.
•Support surfaces – special beds, pads, cushions and mattresses may all help reduce pressure on a sore, as well as protect likely areas from further breakdown. The type of support used depends on the patient’s mobility, their build, as well as the severity of the ulcer. Pillows and rubber rings should be avoided to cushion a wheelchair – air-filled, water-filled or foam devices are better. Experts say that low-air-loss beds or air-fluidized beds are better.
The following non-surgical treatments for pressure ulcers are also possible:
•Clean wound – the wound must be kept clean. If it is a Stage I wound, it may be gently washed with water and a mild soap. Open sores, on the other hand, need to be cleaned with a saline solution each time the dressing is changed. Hydrogen peroxide or iodine should be avoided.
•Continence – this must be controlled as much as possible. The patient may be helped with lifestyle changes, behavioral programs, incontinence pads as well as certain medications.
•Debridement – a wound does not heal well if dead or infected tissue is present. The dead or infected tissue needs to be removed.
oSurgical debridement – the doctor uses a scalpel to remove dead tissue (other devices are possible).
oMechanical debridement – a high-pressure irrigation device removes devitalized tissue.
oAutolytic debridement – the body’s own enzymes break down dead tissue.
oEnzymatic debridement – topical debriding enzymes are applied.
oUltrasound – dead tissue is removed using low-frequency energy waves.
oLaser – dead tissue is removed using focused light beams.

•Maggot therapy (larvae therapy) – this is an alternative method of debridement. The maggots feed on dead and infected tissue, but do not touch healthy tissue. They also release substance that kill bacteria and encourage healing. The maggots are placed into the wound dressing and the area is covered with gauze. A few days later the dressing and the maggots are removed.
•Dressings – these are key to protecting the wound and accelerating healing. The type of dressing used depends on the severity of the wound. Basically, the wound must be kept moist, while the surrounding tissue has to stay dry. A Stage I sore does not usually require covering. Stage II wounds are generally treated with hydrocolloids, or transparent semi-permeable dressings’ that hold the moisture in and accelerate skin cell growth. Special dressings may be used for weeping wounds, or those with surface debris. An antibiotic cream may be used for contaminated sores.
•Hydrotherapy – the skin may be kept clean with whirlpool baths. They may also naturally remove dead or contaminated tissue.
•Oral antibiotics – the patient may be given oral antibiotics if the pressure ulcers are infected.
•Nutrition – wound healing may be enhanced if the patient eats properly. This includes adequate supplies of protein, vitamins and minerals (especially vitamin C and zinc), and enough calories.
•Relief from muscle spasms – skeletal muscle relaxants that block nerve reflexes in the spine or in the muscle cells may alleviate spasticity.
Surgery Some bedsores may become so severe that surgical intervention is necessary, regardless of treatment received. Surgery aims to improve the appearance of the sore, clean it up, treat or prevent infection, reduce fluid loss, and lower the risk of subsequent cancer.

Typically, a pad of muscle, skin or other tissue from the patient’s own body is used to cover the wound and cushion the affected bone (flap reconstruction).
Prevention of pressure ulcers
Experts all agree that it is far easier to prevent bed sore than to treat them. However, easier does not necessarily mean easy. With the appropriate measures, patients and medical staff can significantly reduce the risk of developing pressure ulcers.

The Mayo Clinic, USA, recommends that patients and medical staff develop a plan that all can follow; this must include position changes, supportive devices, routine skin inspections and good diet.
•Position changes – the prevention of bed sores depends largely on regular position changes. It does not take long for a pressure ulcer to start developing. That is why experts say positions should change every 15 minutes or so for those on a wheelchair and at least once every two hours for people in bed, even during the night-time hours (if the patient spends most of his/her time in bed). Patients who cannot do this unaided will need help.
•Best positions in bed – a qualified physical therapist should advise the patient on the best positions. These may include:
oHip bones – lie on your side at a 30-degree angle, do you lie directly on your hipbone. Make sure your legs are suitably supported – if you are lying on your back place a foam pad or a pillow under your legs from the middle of your calf to your ankle. Do not use a doughnut-shaped cushion, as it can cut your circulation.
oKnees and ankles – to prevent them from touching each other use small pillows or pads.
oHead of the bed – do not raise the head of the bed more than 30 degrees, to minimize the risk of friction.
oType of bed – pressure-reducing mattresses or beds are best. This may include foam, air, gel or water mattresses.

•Wheelchairs – pressure-release allow for longer periods of sitting. Patients without a pressure-release chair will need to change their position every 15 minutes, or thereabouts. Wheelchairs need cushions that reduce pressure while providing support and comfort.
•Skin inspections – these should be done daily. Use a mirror if you have to, or ask a family member or caregiver to help you. People who spend long periods in bed should check their hips, spine, shoulder blades, elbows, heels and lower back especially carefully. People on wheelchairs should check their buttocks, tailbone (coccyx), lower back, legs, heels and feet carefully.
•Diet – good nutrition is crucial for skin health and proper healing. It is sad that those who are at high risk of pressure ulcers tend to be more malnourished than other people. Talk to a qualified nutritionist or dietitian about what is most suitable for you.
•Smoking – if you smoke regularly, giving up may be the single best thing you can do to prevent pressure ulcers, and help a more rapid and likely recovery if they do occur.
•Exercise – exercise helps circulation, builds muscle, improves overall health and stimulates a healthy appetite. Talk to a physical therapist about which exercise options are best for you.
What are the possible complications of pressure ulcers?
•Cellulitis – a bacterial infection of the dermis – the deep layer of skin – as well as the subcutaneous tissues (fat and soft tissue layer) that are under the skin. Cellulitis can result in life-threatening complications, including septicemia (blood poisoning), and the spreading of infection to other parts of the body. People with cellulitis also risk eventually having a permanent swelling around the affected area.
•Bone and joint infections – if a pressure ulcer makes its way into the joints or bones, there is a serious risk of infection, resulting in damage to cartilage and tissue from joint infections, and a reduction in limb and joint function for bone infections.
•Sepsis – bacteria can enter through sores, especially advanced ones, and infect the bloodstream. There is then a serious risk of shock and organ failure, a life-threatening condition.
•Cancer – there is a higher risk of developing an aggressive carcinoma in the skin’s squamous cells if the patient has bed sores.

        

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