What Are Bedsores?

They owe their origin to the observation that patients who were bedridden and not properly repositioned, would often develop ulcerations on their skin, usually over bony prominences.  Such sores, which result from prolonged pressure, are also called
“decubitus ulcers” or “pressure ulcers/sores”.  

Bedsores can develop within short periods – hours – and progress rapidly and are difficult to heal, till the inciting factor is removed.

So bedridden patients, paralyzed patients who cannot move by themselves or those who are unconscious and unable to feel the pain of sustained pressure are especially at risk.

Common Sites for Bedsores

Importantly bed sores do not always result from being in bed as the name implies. The location of the ‘bed sores’ usually depends upon the position of the patient.

Sacrum & Lower Back

Tailbone area under prolonged pressure on mattress.

Heels & Hip

Heels and hip pressed cause circulation blockage.

Pressure ulcers may also develop in a number of other areas, including the spine, ankles, knees, shoulders, and head, depending upon the position of the patient. Prolonged sitting may also contribute to formation of such ulcers especially in wheelchairs. 

Causes of Bedsore

Sideways movement between two surfaces is shear. Your skin moves in one direction and the underlying bony and tendinous tissue moves in the opposite direction of movement. This happens when you slide down in a bed or chair. This force tears the capillaries and superficial skin layers and predisposes to the development of such wounds.

When the skin and the underlying tissues are trapped two surfaces such as between bone and an external surface then the pressure prevents sufficient blood flow to supply the tissues with nutrients. The external surface may be a mattress, a chair or wheelchair, or even other parts of the body. The resulting bed sore represents the death of the involved soft tissue. This tends to happen in areas that aren’t well padded with muscle or fat and that lie just over a bone. For bed-bound patients, the sores are most likely to form on or around the lower back or tailbone – the commonest area in intensive care units -,  the heels (especially in diabetics), & the hip-bone.  Pressure ulcers(BED SORES) may also develop in a number of other areas, including the spine, ankles, knees, shoulders, and head, depending upon the position of the patient.  Prolonged sitting may also contribute to formation of such ulcers especially in wheelchairs .

Sideways movement between two surfaces is shear. Your skin moves in one direction and the underlying bony and tendinous tissue moves in the opposite direction of movement. This happens when you slide down in a bed or chair. This force tears the capillaries and superficial skin layers and predisposes to the development of such wounds.

Risk Factors

Pressure sores/BEDSORES are more likely to develop persons who are at higher risk due to one or more risk factors. The common ones being:

Older adults tend to have thinner skin than younger people do, making them more susceptible to damage from minor pressure. They’re also more likely to be underweight, with less natural cushioning over their bones.

Persons confined to beds or wheelchairs and unable to move themselves, can develop pressure-induced injuries in as little as 1-2 hours if the pressure is not relieved— even for a brief time such as after an operation or accident is enough if associated risk factors are present.

Unconscious or paralyzed individuals or those recovering after a surgery like of the hip or other mobility limitation, need help to change positions

Sources of moisture on the skin from urine, stool, or perspiration can irritate the skin –leading to maceration and development of BEDSORES on pressure areas – something akin to web space injuries due to long periods of immersion of the feet in water or accumulation of perspiration in between the spaces.

Sores are more likely to form when the skin is not properly nourished.

An individual with decreased mental awareness may not have the level of sensory perception or ability to act to prevent the development of pressure-induced
injury.  The lack of mental awareness may also arise from medications.

Smokers tend to develop more severe wounds and heal more slowly, mainly because nicotine impairs circulation and reduces the amount of oxygen in your blood.

Complications

Pressure sores can trigger other ailments, cause patients considerable suffering, and be expensive to treat.

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Complications Listed Below:

One of the greatest dangers of an advanced pressure sore, 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 shock and organ failure. 

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 bedsore burrows deep into your joints and bones. Joint infections (septic or infectious arthritis) can damage cartilage and tissue, whereas bone infections (osteomyelitis) may reduce the function of your joints and limbs. 

Marjolin’s Ulcer.A rare skin cancer, more common in scar tissue .

Treatment

The best treatment outcomes will result from using a multidisciplinary team of specialists, to ensure all problems are addressed. Units specializing in wound care like Savelegs Diabetic Foot & Wound Care Centre, are able to give better results when compared to other units.

The most important care is the relief of pressure. Once a bed sore is found, pressure should immediately be removed from the area and the patient turned at least every two hours to avoid aggravating the wound and preventing the development of newer wounds. Ensuring dry sheets regular changes of linen alongwith the use of catheters or impermeable dressings.

For paralyzed individuals, pressure shifting on a regular basis and use of a pressure relief sheet like a silicone gel sheet,can help prevent pressure wounds.

Pressure-distributive mattresses, water mattresses & Air mattresses are used to reduce high values of pressure on prominent or bony areas of the body.

Removal of dead/necrotic tissue is an absolute must in the treatment of pressure ulcers. Dead tissue is an ideal medium for infection and greatly reduces wound healing and the ability of the body to repair itself. Various methods are used to remove such tissue

Autolytic Debridement – the use of moist dressings to promote autolysis with the body’s own enzymes- Though slow it is painless

Maggots – In some countries maggots are used for the purpose but not yet available in India.

Enzymatic Debridement – The use of certain enzymes to promote removal of dead tissue.

Surgical Debridement – The removal of such tissue by surgical means

Mechanical Debridement – The use of mechanical means like pressure water jets to remove the tissue.

Ultrasonic Debridement – The use of ultrasound waves to remove dead tissue.

These modalities may be used individually or in various combinations as the wound progresses.

Local as well as systemic infection needs to be controlled. This may involve the use of antibiotics for systemic control and the use of local wound dressings to remove infection locally. The advent of newer dressings like ionic silver has been a breakthrough in this regard.

Once the systemic signs settle, usually the use of oral and parenteral antibiotics is avoided.

The best diet to support healing is prescribed to such patients, as a malnourished person does not have the ability to synthesize enough protein to repair tissue.Protein levels, leucocyte counts, thyroid profiles and other blood tests may be conducted ,if malnourishment is suspected.

Based on these or clinical exams, the physician may start dietary supplements and various nutrients including parenteral supplements depending upon the condition of the patient.

There is anecdotal evidence that high protein diet helps healing of sores.

If the patient is to be shifted to the house, it is very important to educate the family about how to treat the pressure ulcers. The caregiver should be trained in the proper way to turn the patient, how to properly dress the wound & nourish the patient. If possible a system of online access using technology or domiciliary visits by a trained member of the team should be in place, so that the difficulty experienced by the caregivers in bringing the patient to hospital can be avoided.

Given that these are chronic problems which cause a emotional, financial and mental drain on the family and caregivers, a program of psychological counseling and guidance for them should be adhered to..

Once the patient has reached the point that intervention is possible, there are many different options.

For Stage I & II sores, usually just removal of pressure and wound care using accepted guidelines in usually enough.

For Stage III & IV ulcers, the use of tissue flaps or other closure methods used to be the treatment of choice. However with the advent of Negative Pressure Wound Therapy, advanced dressing materials and various pressure reducing beds and devices, it may now be possible to close such wounds without major surgical intervention.

These patients need regular evaluation to determine future course of action.

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