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| Bedsores |
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 Bedsores
are a common health problem in hospitals, nursing homes and in homes all
over the world, where people are confined to their beds. For example,
in the US, approximately 9 percent of all hospitalized patients and 9
percent of patients in home care are affected by bedsores. The risk for
bedsores increases with age, especially in persons over age 85. Many elderly
patients suffer from bedsores at more than one skin site.
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| What are bedsores? Why do they develop? |
Bedsores, also called "pressure ulcers" or "decubitus
ulcers," are areas of broken skin that can develop in persons who have been
confined to bed for extended periods of time. Bedsores generally occur at
points of pressure - over the spine, lower back, shoulder blades, elbows
and heels - at places where the weight of a patient's body presses the skin
against the firm surface of the bed.
This pressure temporarily cuts off the blood supply to the skin, which leads
to the injury and death of skin cells.
Unless pressure is relieved and normal circulation resumes, the affected
skin soon begins to show signs of injury. |
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| Sites on the body where bedsores are common |
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| What are the other factors contributing to formation
of bedsores? |
| Persistent pressure on the skin is the most important
reason for the development of bedsores, but other factors too can be responsible:
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| Shearing forces and friction :Shearing and
friction cause rubbing and superficial irritation of the skin surface, which
increase the skin's vulnerability to damage from pressure. In a patient
who is confined to bed, some important sources of shearing and friction
are: |
- Dragging or sliding a patient across the bed sheets,
- Allowing the patient's unprotected elbows or heels to rub against
the surface of the bed
- Raising the head of the bed more than 30 degrees (this increases shearing
forces over the lower back and tail bone).
- Shearing and friction cause rubbing and superficial irritation of
the skin surface, which increase the skin's vulnerability to damage
from pressure.
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| Moisture: Wetness from perspiration, urine
or feces can increase the skin's vulnerability to damage from pressure.
For this reason, patients who suffer from incontinence are at particularly
high risk for bedsores. |
Decreased movement: Patients who can move
without assistance have a lower risk of bedsores because they are capable
of periodically shifting their weight away from vulnerable areas of skin.
Bedsores are also common in patients who are immobilized because of any
of the following problems: severe arthritis, prolonged recuperation from
surgery, extended treatment in an intensive care unit or incapacitating
neurological problems (stroke, spinal cord injury, multiple sclerosis). |
| Decreased sensation: Bedsores are common
in persons who have spinal cord injuries or other neurological problems
that decrease the capacity to feel pain or discomfort. Without normal sensation,
the patient cannot feel the effects of prolonged pressure on the skin and
may not ask for assistance in shifting pressure away from the affected area. |
| Circulatory problems: Persons with atherosclerosis,
circulatory problems from long-term diabetes or localized edema (swelling)
have an increased risk of bedsores. This risk is increased because the blood
flow in their skin is less than ideal, even before the skin is exposed to
pressure. Persons with anemia are also at risk, because their blood cannot
carry optimum levels of oxygen to skin cells, although their skin circulation
may be normal. |
| Poor nutrition: If a patient is poorly nourished,
the vulnerability to bedsores increases. Specifically, studies show that
bedsores are more likely to develop in patients who have an inadequate daily
intake of protein, vitamin C, vitamin E, calcium or zinc. |
| Age: Elderly individuals have an increased
risk of bedsores because the skin usually becomes thinner with age. Also,
superficial fat tends to shift away from the body surface (where it acts
as a cushion) to be deposited in deeper areas of the body. |
| Wheelchairs: As in bedridden patients, the
skin damage is related to persistent pressure on vulnerable areas, usually
in skin that is compressed against the chair during sitting. |
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| How do bedsores progress? |
| According to their progress, bedsores are sometimes
classified into four stages. This depends on the severity of skin damage: |
- Stage I (earliest signs of skin damage) — There is a persistent
patch of red skin that does not blanch (turn white) when pressed with
a finger. The affected skin may also be tender or itchy, and it may
feel warm and firm to the touch.
- Stage II — There is blistering or an ulcer (open sore) that
does not extend through the full thickness of the skin. There may also
be a surrounding area of redness or purple discoloration, mild superficial
swelling and some oozing.
- Stage III — The ulcer has become a crater and invades subcutaneous
tissues (soft tissues just below the skin surface).
- Stage IV — The crater has eroded into a muscle, bone, tendon
or joint.
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A note on infections: Because the broken
skin of a bedsore is a prime target for bacteria, bedsores are extremely
vulnerable to infections. This is especially true if the sore is frequently
contaminated by the urine or feces of a patient who has incontinence.
Signs of infection in a bedsore include: |
- Pus draining from the sore
- A foul-smelling odor
- Tenderness, heat and increased redness in the surrounding skin
- Fever (sometimes).
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| Are bedsores serious? |
Bedsores can be serious, depending on how much
of the skin and tissues have been damaged. Because the broken skin of a
bedsore is a prime target for bacteria, bedsores are extremely vulnerable
to infections. This is especially true if the sore is frequently contaminated
by the urine or feces of a patient who has incontinence.
Pressure sores that become infected heal more slowly and can spread a dangerous
infection (septicemia) to the rest of the body. If left untreated, a serious
infection called gangrene could develop, which could be life threatening.
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| Here are some signs to indicate that an infection
has developed: |
- Thick yellow or green pus
- A bad smell from the sore
- Redness or warmth around the sore
- Swelling around the sore
- Tenderness around the sore
- Signs that the infection may have spread include:
- Fever or chills
- Mental confusion or difficulty concentrating
- Rapid heartbeat
- Weakness
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| How does the doctor diagnose bedsores? |
| A doctor can make the diagnosis by examining the
patient's skin. Special diagnostic tests are usually unnecessary unless
there are symptoms of infection. |
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| When are lab investigations necessary? |
| If a patient with bedsores develops symptoms of
infection, then a doctor may order diagnostic tests to determine whether
the infection has invaded the soft tissues, bones, bloodstream or some other
site. These tests may include a complete blood count, a culture of the infected
bedsore, blood cultures to rule out sepsis, and bone X-rays to look for
evidence of osteomyelitis. |
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| How can a person who is caring for someone who
is bedridden or prone to developing ulcers, recognise a bedsore? |
| A doctor will be able to guide a person caring
for a family member who is confined to a bed or wheelchair, to identify
the earliest signs of bedsores. The patient will be shown the areas of skin
that are particularly vulnerable and the signs to look out for. Once a person
has learned to recognize the earliest signs of skin damage, one can take
steps to prevent areas of redness from progressing to full-blown ulcers. |
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| What is the relationship between diabetes and
bedsores? |
| Extra precaution has to be taken if a person with
diabetes becomes bedridden. The reasons are: |
- Diabetics are more prone to infections.
- Infections in diabetics take longer to heal than usual, because the
blood supply to the skin is reduced.
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| Normally, pain is perceived in areas of the foot
that are subject to excessive pressure. This leads a person son to shift
one's weight and thus reduce pressure on the painful area. When diabetic
neuropathy is present, such impulses are not perceived, which leads to further
pressure being applied on an already traumatized area. For these reasons
a person who is caring for a bedridden patient with diabetes, should be
more vigilant in recognizing any redness of the skin and start appropriate
treatment when required. |
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| How long do bedsores last? |
Many factors influence the duration of a bedsore,
including the stage of the bedsore, the type of treatment and the patient's
age, overall health, nutrition and mobility. For example, there is a good
chance that a Stage II bed sore will heal within one to six weeks in a relatively
healthy older person who eats well and is not immobilized. Deeper Stage
II and Stage IV ulcers may take six weeks to three months.
On the other hand, bedsores can be an ongoing problem in chronically ill
patients who have multiple risk factors (incontinence, immobility, circulatory
problems, etc.). In these patients, the fight against bedsores is often
a long-term battle. |
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| How can one prevent bedsores? |
| Using simple measures to relieve pressure and decrease
the skin's vulnerability to injury can prevent 50 percent of bedsores. To
help prevent bedsores in a patient who is confined to a bed or chair, the
following methods could be tried: |
| Relieving pressure on vulnerable areas of skin |
- Changing the patient's position every two hours when he or
she lies in bed and every hour when he or she sits in a chair.
- Using pillows if necessary to raise the patient's arms, legs, buttocks
and hips.
- Relieving pressure on the patient's back with an egg-crate foam mattress
or a special mattress such as a water mattress.
- Air-fluidized beds and low-air-loss beds are ideal but expensive.
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| Reducing shear and friction |
- Avoiding dragging of the patient across the bed sheets. Instead, either
lifting the patient or encouraging the patient to use a trapeze to briefly
raise his or her body are ideal.
- Keeping the bed free from small particles that can rub and irritate
the skin.
- The head of the bed should not be raised more than 30 degrees, unless
otherwise instructed by the doctor.
- When the patient is given a wash, one should take care to cleanse
gently and avoid rubbing or scrubbing the skin.
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| Inspecting the patient's skin at least once each
day |
| Early detection can prevent Stage I redness from
becoming Stage II ulcers, or worse. |
| Minimizing irritation from chemicals |
| Avoiding use of irritating antiseptics, hydrogen
peroxide, povidone iodine solution or other harsh chemicals to clean or
disinfect the skin. |
| Encouraging the patient to eat well |
| The patient's diet should include adequate calories,
protein, calcium, zinc and vitamins C and E. If food intake is poor, a doctor
should be consulted about giving the patient nutritional supplements. |
| Encouraging daily exercise |
| Exercise increases blood flow and speeds healing.
In many cases, even bedridden patients can perform stretches and isometric
exercises. |
| Keeping the skin clean and dry |
- Cleaning the skin with saline (a non-irritating salt solution) rather
than harsh soaps.
- As necessary, using absorbent pads to draw moisture away from vulnerable
areas.
- If the patient is incontinent, a doctor should be consulted about
ways to control or limit the leakage of urine or feces.
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| How are bedsores treated? |
Prime importance is given to prevent bedsores in
the elderly and in those confined to their beds. But once a bedsore has
developed, care should be taken to treat it immediately to avoid further
damage and serious consequences. Treatment of a bedsore depends on the stage
of the bedsore.
A doctor should be consulted, if a suspicious area of redness or blistering
is seen.
Areas of unbroken skin near the bedsore are covered with a protective barrier
film or a moisture barrier lubricant to protect them from injury. Next,
special dressings are applied to either promote healing or help remove small
areas of dead tissue. If necessary, larger areas of dead tissue may be trimmed
away surgically or dissolved with an enzymatic debriding agent (a medication
that uses enzymes to dissolve dead tissue).
Deep craters may need skin grafting and other forms of reconstructive surgery.
If a patient's skin does not begin to heal within a few days after treatment
starts, the doctor may prescribe antibiotics (ointments, pills or intravenous
infusion). Antibiotics are also used to treat bedsores that show obvious
signs of infection. |
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| What is the prognosis for this condition? |
The same factors that influence the duration of
a bedsore also influence its prognosis. In many cases, the prognosis is
good if the condition is recognised early and treatment is begun immediately.
Simple bedside treatments can heal most Stage II bedsores within a few weeks.
If conservative methods fail to heal a Stage III or Stage IV bedsore, reconstructive
surgery can often repair the damaged area.
Even after a bedsore heals, skin injury can recur if the vulnerable area
is not protected from pressure and other irritants. To stop such injury,
the methods outlined above to prevent bedsores should be followed. |
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