I worked for twenty years as a nurse, and for the last 10 years I specialized in elder care in a nursing home facility. The most common threat to the elder patient was the development of decubitus ulcers. A decubitus ulcer is a bedsore, also called a pressure sore. Bedsores are caused by continuous pressure to an area where there is a bony prominence.
Bedsores are categorized into 4 stages:
Stage I-is the very beginning of a decubitus ulcer. It hasn’t even broken the skin at this time. At this stage the bedsore appears to be only a reddened area on the skin. This reddened area does not go away when pressure is removed. It should be noted that on light skinned people the area will appear reddened, but in dark skinned people this area will appear blue or purple in color.
Stage II-this is when the tissue is damaged on the outer layers of the skin and goes into the inner layer of the skin called the dermis. This is the area where the sweat glands, nerves, and hair follicles live. At this stage the ulcer appears look like an abrasion or a blister.
Stage III-At this stage the decubitus ulcer is a full thickness injury to the skin and all the structures within, but does not go deeper into the subcutaneous layer which contains the adipose tissue, or what is commonly called fat cells.
Stage IV-this is the deepest of all the decubitus ulcers, the most serious and the most difficult to treat. At this stage the decubitus ulcer has eroded into muscle, connective tissue and bone. As in all the stages of pressure sores, the wound becomes more involved as tissue is starved of blood flow, which contains life giving nutrients and oxygen.
In stages III and IV many ulcers cannot be properly staged until a hard thick layer of skin cells and tissue exudates is removed. This layer is called eschar, which is a very thick scab that forms over the wound in an attempt to protect it. This sometimes can be done in a doctor’s office or sometimes it needs surgical intervention.
What causes bedsores?
1.Pressure is the cause of most bedsores. The tissue becomes compressed between the force of the bone against the harder surface of the bed and the surface of the skin. As a result the skin is robbed of oxygen and the tissue dies through a process called necrosis.
2.Shearing action is a force exerted on the skin and inner tissues as the inner tissues slide with gravity and the outer surface of the skin does not move. This causes trauma on the inner connective tissue by pinching the tissue and the capillaries causing an interruption of blood flow to the area. The result is necrosis of the tissue.
3.Friction is similar to shearing, in that the friction between the bed and the skin causes the cells to be sheared off. This causes a reddened area to form and sometimes a blister, which will eventually erode into the deep tissues if not cared for properly.
A patient with decubitus ulcers should have a diet rich in protein and vitamins for wound healing. It takes lots of calories to rebuild tissue, so several small meals and supplements should be offered to the patient. In many patients, they don’t feel well and may not want to eat or drink supplements, but they should be encouraged to promote wound healing.
The main cause of bed sores is constant unrelieved pressure, and the prevention is to relieve pressure frequently to bedridden patients. The patient should be repositioned at least every 2 hours. This allows oxygen and nutrients to enter the cells of those boney prominences, and breakdown will not occur in healthy cells.
Bedsores cause much pain and suffering for the patient, and they are difficult and expensive to treat because they take so long to heal. Bedsores are not the only problem in an immobile patient. Complications from the bedsore can develop such as, gangrene, bone infections, and sepsis. Any one of these complications can lead to a life-threatening condition called sepsis.
Decubitus ulcers can be prevented by repositioning the patient at least every 2 hours. The patient may have a loss of sensation and may not feel the need to turn, but the caregiver needs to be diligent in making sure the patient is turned regularly.
Where I worked if a patient came in with clear skin, but developed a bedsore while in our facility, that meant that the staff was not doing their job. If a patient develops a bedsore it is evident that he or she has not been repositioned often enough, and that is considered to be abuse because they are preventable.
For more information on decubitus ulcers please go to the E-medicine website from WebMD at: http://www.emedicine.com/med/topic2709.htm
