Bedsores (pressure sores)
Definition:
Bedsores — also called pressure sores or pressure ulcers — are injuries
to skin and underlying tissues that result from prolonged pressure on
the skin. Bedsores most often develop on skin that covers bony areas of
the body, such as the heel, ankles, hips or buttocks.
People most at risk of bedsores are those with a medical condition that
limits their ability to change positions, requires them to use a
wheelchair or confines them to a bed for prolonged periods.
Bedsores can develop quickly and are often difficult to treat. Several
care strategies can help prevent some bedsores and promote healing
Symptoms:
Bedsores fall into one of four stages based on their severity. The
National Pressure Ulcer Advisory Panel, a professional organization that
promotes the prevention and treatment of pressure ulcers, has defined
each stage as follows.
Stage I
The beginning stage of a pressure sore has the following characteristics:
- The skin is intact.
- The skin appears red on people with lighter skin color, and the skin doesn't briefly lighten (blanch) when touched.
- On people with darker skin, there may be no change in the color of
the skin, and the skin doesn't blanch when touched. Or the skin may
appear ashen, bluish or purple.
- The site may be painful, firm, soft, warmer or cooler compared with the surrounding skin.
Stage II
The stage II ulcer is an open wound:
- The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost.
- The pressure ulcer may appear as a shallow, pinkish-red, basin-like wound.
- It may also appear as an intact or ruptured fluid-filled blister.
Stage III
At this stage, the ulcer is a deep wound:
- The loss of skin usually exposes some amount of fat.
- The ulcer has a crater-like appearance.
- The bottom of the wound may have some yellowish dead tissue (slough).
- The damage may extend beyond the primary wound below layers of healthy skin.
Stage IV
A stage IV ulcer exhibits large-scale loss of tissue:
- The wound may expose muscle, bone and tendons.
- The bottom of the wound likely contains slough or dark, crusty dead tissue (eschar).
- The damage often extends beyond the primary wound below layers of healthy skin.
Common sites of pressure sores
For people who use a wheelchair, pressure sores often occur on skin over the following sites:
- Tailbone or buttocks
- Shoulder blades and spine
- Backs of arms and legs where they rest against the chair
For people who are confined to a bed, common sites include the following:
- Back or sides of the head
- Rim of the ears
- Shoulders or shoulder blades
- Hip, lower back or tailbone
- Heels, ankles and skin behind the knees
When to see a doctor
Inspection of the skin should be a part of routine nursing or home care
for anyone who is confined for a long time to a wheelchair or bed or for
anyone who has limited ability to reposition himself or herself.
Contact your doctor right away if you notice any signs or symptoms of a
pressure ulcer. Get immediate medical care if a person under your care
shows signs of infection, such as fever, drainage or foul odor from a
sore, or increased heat and redness in the surrounding skin.
Causes:
Pressure sores are caused by pressure against the skin that inhibits an
adequate supply of blood to skin and underlying tissues. Other factors
related to limited mobility can make the skin vulnerable to damage and
contribute to the development of pressure sores. There are three primary
contributing factors:
- Sustained pressure. When your skin and the
underlying tissues are trapped between bone and a surface such as a
wheelchair or bed, the pressure may be greater than the pressure of the
blood flowing in the tiny vessels (capillaries) that deliver oxygen and
other nutrients to tissues. Deprived of these essential nutrients, cells
of the skin and other tissues are damaged and may eventually die. This
kind of pressure tends to happen in areas that aren't well padded with
muscle or fat and that lie just over a bone, such as your spine,
tailbone (coccyx), shoulder blades, hips, heels and elbows.
- Friction. Friction is the resistance to motion.
When a person changes position or is handled by care providers, friction
may occur when the skin is dragged across a surface. The resistance to
motion may be even greater if the skin is moist. Friction between skin
and another surface may make fragile skin more vulnerable to injury.
- Shear. Shear occurs when two surfaces move in the
opposite direction. For example, when a hospital bed is elevated at the
head, a person can slide down in bed. As the tailbone moves down, the
skin over the bone may stay in place — essentially pulling in the
opposite direction. This motion may damage tissue and blood vessels,
making the site more vulnerable to damage from sustained pressure.
Complications:
Complications of pressure ulcers include:
- Sepsis. Sepsis occurs when bacteria enters your
bloodstream through the broken skin and spreads throughout your body — a
rapidly progressing, life-threatening condition that can cause organ
failure.
- Cellulitis. This acute infection of your skin's
connective tissue causes pain, redness and swelling, all of which can be
severe. Cellulitis can also lead to life-threatening complications,
including sepsis and meningitis — an infection of the membrane and fluid
surrounding your brain and spinal cord.
- Bone and joint infections. These develop when the
infection from a pressure sore burrows deep into your joints and bones.
Joint infections (septic or infectious arthritis) can damage cartilage
and tissue, and bone infections (osteomyelitis) may reduce the function
of your joints and limbs.
- Cancer. Another complication is the development of a
type of squamous cell carcinoma that develops in chronic, nonhealing
wounds (Marjolin ulcer). This type of cancer is aggressive and usually
requires surgical treatment.
Treatments and drugs:
Stage I and stage II pressure sores usually heal within several weeks to
months with conservative care of the wound and with ongoing,
appropriate general care that manages risk factors for pressure sores.
Stage III and IV pressure sores are more difficult to treat. In a person
who has a terminal illness or multiple chronic medical conditions,
pressure sore treatment may focus primarily on managing pain rather than
complete healing of a wound.
Treatment team
Addressing the many aspects of wound care usually requires a multidisciplinary approach. Members of a care team may include:
- A primary care physician who oversees the treatment plan
- A physician specializing in wound care
- Nurses or medical assistants who provide both care and education for managing wounds
- A social worker who helps a person or family access appropriate
resources and addresses emotional concerns related to long-term recovery
- A physical therapist who helps with improving mobility
- A dietitian who assesses nutritional needs and recommends an appropriate diet
- A neurosurgeon, orthopedic surgeon or plastic surgeon, depending on
whether surgery is required and what type of surgery is needed
Relieving pressure
The first step in treating a sore at any stage is relieving the pressure
that caused it. Strategies to reduce pressure include the following:
- Repositioning. A person with pressure sores needs
to be repositioned regularly and placed in correct positions. People
using a wheelchair should change position as much as possible on their
own every 15 minutes and should have assistance with changes in position
every hour. People confined to a bed should change positions every two
hours. Lifting devices are often used to avoid friction during
repositioning.
- Support surfaces. Special cushions, pads,
mattresses and beds can help a person lie in an appropriate position,
relieve pressure on an existing sore and protect vulnerable skin from
damage. A variety of foam, air-filled or water-filled devices provide
cushion for those sitting in wheelchairs. The type of devices used will
depend on a person's condition, body type and mobility.
Removing damaged tissue
To heal properly, wounds need to be free of damaged, dead or infected
tissue. Removing these tissues (debridement) is accomplished with a
number of methods, depending on the severity of the wound, your overall
condition and the treatment goals. Options include:
- Surgical debridement involves cutting away dead tissues.
- Mechanical debridement uses one of a number of
methods to loosen and remove wound debris, such as a pressurized
irrigation device, a whirlpool water bath or specialized dressings.
- Autolytic debridement, the body's natural process
of recruiting enzymes to break down dead tissue, can be enhanced with an
appropriate dressing that keeps the wound moist and clean.
- Enzymatic debridement is the use of chemical enzymes and appropriate dressings to break down dead tissues.
Cleaning and dressing wounds
Care that promotes healing of the wound includes the following:
- Cleaning. It's essential to keep wounds clean to
prevent infection. A stage I wound can be gently washed with water and
mild soap, but open sores are cleaned with a saltwater (saline) solution
each time the dressing is changed.
- Dressings. A dressing promotes healing by keeping a
wound moist, creating a barrier against infection and keeping the
surrounding skin dry. A variety of dressings are available, including
films, gauzes, gels, foams and various treated coverings. A combination
of dressings may be used. Your doctor selects an appropriate dressing
based on a number of factors, such as the size and severity of the
wound, the amount of discharge, and the ease of application and removal.
Other interventions
Other interventions that may be used are:
- Pain management. Interventions that may reduce pain
include the use of nonsteroidal anti-inflammatory drugs — such as
ibuprofen (Motrin, Advil, others) and naproxen (Aleve, others) —
particularly before and after repositioning, debridement procedures and
dressing changes. Topical pain medications, such as a combination of
lidocaine and prilocaine, also may be used during debridement and
dressing changes.
- Antibiotics. Pressure sores that are infected and don't respond to other interventions may be treated with topical or oral antibiotics.
- Healthy diet. Appropriate nutrition and hydration
promote wound healing. Your doctor may recommend an increase in calories
and fluids, a high protein diet, and an increase in foods rich in
vitamins and minerals. Your doctor may also prescribe dietary
supplements, such as vitamin C and zinc.
- Muscle spasm relief. Muscle relaxants — such as
diazepam (Valium), tizanidine (Zanaflex), dantrolene (Dantrium) and
baclofen — may inhibit muscle spasms and enable the healing of sores
that may have been caused or worsened by spasm-related friction or
shearing.
Surgical repair
Pressure sores that fail to heal may require surgical intervention. The
goals of surgery include improving the hygiene and appearance of the
sore, preventing or treating infection, reducing fluid loss through the
wound, and lowering the risk of cancer.
The type of reconstruction that's best in any particular case depends
mainly on the location of the wound and whether there's scar tissue from
a previous operation. In general, though, most pressure wounds are
repaired using a pad of the person's own muscle, skin or other tissue to
cover the wound and cushion the affected bone (flap reconstruction).
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