Bedsore
Encyclopedia
Bedsores, more properly known as pressure ulcers or decubitus
ulcers, are lesion
s caused by many factors—such as unrelieved pressure, friction, humidity, shearing forces, temperature, age, continence, and medication—to any part of the body, especially portions over bony
or cartilaginous
areas such as sacrum
, elbows, knees, and ankles. Although often prevented and treatable if found early, they can be very difficult to prevent in frail elderly patients, wheelchair users (especially where spinal injury is involved) and terminally ill patients. Bedsores are often fatal—even under the auspices of medical care—and are one of the leading iatrogenic causes of death reported in developed countries, second only to adverse drug reaction
s. The primary cure and treatment is to remove the pressure by turning the patient regularly (every two hours is often quoted, though the evidence for this figure is not strong and four hourly turns may be as effective in some patients). However the relief of pressure to avoid further sores is well documented since at least the 19th century; regular turning was advised to prevent sores by Galloway (though some of her other recommendations are not current practice, for example massage of the pressure area is probably contra-indicated) and virtually all authors since.
Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
With higher stages, healing time is prolonged. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year. It is important to note that pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer).
Aggravating the situation may be other conditions such as excess moisture from incontinence
, perspiration or exudate
. Over time, this excess moisture may cause the bonds between epithelial cells to weaken thus resulting in the maceration of the epidermis. Temperature is also a very important factor. The cutaneous metabolic demand rises by 13% for every 1°C rise in cutaneous temperature. When supply can't meet demand, necrosis
therefore occurs. Other factors in the development of bedsores include age, nutrition, vascular disease, diabetes mellitus
, and smoking
, amongst others.
There are currently two major theories about the development of pressure ulcers. The first and most accepted is the deep tissue injury theory which claims that the ulcers begin at the deepest level, around the bone, and move outward until they reach the epidermis. The second, less popular theory is the top-to-bottom model which says that skin first begins to deteriorate at the surface and then proceeds inward.
when blood re-enters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood
flow to affected areas. Within 2 hours, this shortage of blood supply, called ischemia
, may lead to tissue
damage and cell
death
. The sore will initially start as a red, painful area, which eventually turns purple. Left untreated, the skin may break open and become infected
. Moist skin is more sensitive to tissue ischemia and necrosis
and is also more likely to get infected.
of bedsores is 0.4% to 38%; within long-term care, 2.2% to 23.9%; and in home care, 0% to 17%. There is the same wide variation in prevalence
: 10% to 18% in acute care, 2.3% to 28% in long-term care, and 0% to 29% in home care. There is a much higher rate of bedsores in intensive care units because of immunocompromised individuals, with 8% to 40% of ICU patients developing bedsores. However pressure ulcer prevalence is highly dependent on the methodology used to collect the data. Using the European Pressure Ulcer Advisory Panel (EPUAP) methodology there is are similar figures for pressure ulcers in acute hospital patients. There are differences across countries, but in Europe (for example) using this methodology pressure ulcer prevalence was consistently high, from 8.3% (Italy) to 22.9% (Sweden). A recent study in Jordan also showed a figure in this range.
The risk of developing bedsores can be determined by using the Braden Scale for Predicting Pressure Ulcer Risk
.
There are seven major contributors to healing.
Nursing home
s and hospital
s usually set programs to avoid the development of bedsores in bedridden patients such as using a standing frame
to reduce pressure and ensuring dry sheets by using catheter
s or impermeable dressings. For individuals with paralysis
, pressure shifting on a regular basis and using a cushion featuring pressure relief components can help prevent pressure wounds.
Pressure-distributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. Antidecubitus mattresses and cushions can contain multiple air chambers that are alternately pumped. However, methods to evaluate the efficacy of these products have only been developed in recent years.
, pain
, redness
, swelling, warmth of the area, and purulent discharge
. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus.
In order to eliminate this problem, it is imperative to apply antiseptics at once. Hydrogen peroxide
is not recommended for this task as it is difficult to balance the toxicity of the wound with this. New dressings have been developed that have cadexomer iodine and silver in them, and they are used to treat bad infections. Duoderm
can be used on smaller wounds to both provide comfort and protect them from infection.
Systemic antibiotics are not recommended in treating infection of a bedsore, as it can lead to bacterial resistance.
to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietitian should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check serum albumin
and lymphocyte
counts. Additionally, a bioelectrical impedance analysis
should be considered.
If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with dietary supplements and nutrients including, but not limited to, arginine
, glutamine
, vitamin A
, vitamin B complex, vitamin E
, vitamin C
, magnesium
, manganese
, selenium
and zinc
. It is very important that intake of these vitamins and minerals be overseen by a physician
, as many of them can be detrimental in incorrect dosages.
There is anecdotal evidence that high protein diet helps healing of sores. High protein diet seems to be especially helpful in sores that do not heal in eight weeks.
As this is a very difficult undertaking, the caregiver may feel overburdened and depressed, so it may be best to bring in a psychological consult.
For those with Stage III or IV ulcers, most interventions will likely include surgery such as a tissue flap, free flap or other closure methods. A more recent intervention is Negative Pressure Wound Therapy
, which is the application of topical negative pressure to the wound. This technique, developed by scientists at Wake Forest University
, uses foam placed into the wound cavity which is then covered in a film which creates an airtight seal. Once this seal is established, the technician is able to remove exudate and other infectious materials in addition to aiding the body produce granulation tissue, the best bed for the creation of new skin.
There are, unfortunately, contraindication
s to the use of negative pressure therapy. Most deal with the unprepared patient, one who has not gone through the previous steps toward recovery, but there are also wound characteristics that bar a patient from participating: a wound with inadequate circulation
, a raw debrided wound, a wound with necrotised tissue and eschar
, and a fibrotic
wound.
After Negative Pressure Wound Therapy
, the patient should be reevaluated every two weeks to determine future therapy.
has published guidelines in 'Pressure ulcer risk assessment and prevention'. It is important to identify those who are at risk and to intervene early with strategies for prevention, in the bed, wheelchair or chair, in the bath and on the commode - indeed, it is a requirement within the National Standards for Care Homes (UK) to do so:
"Standard 8.3 Service users are assessed, by a person trained to do so, to identify those service users who have developed, or are at risk of developing, pressure sores and appropriate intervention is recorded in the plan of care.
8.4 The incidence of pressure sores, their treatment and outcome, are recorded in the service user’s individual plan of care and reviewed on a continuing basis.
8.5 Equipment necessary for the promotion of tissue viability and prevention or treatment of pressure sores is provided."
A wide variety of techniques are used to mitigate the risk of pressure ulcers in at risk groups including: nutritional supplements, topical skin protection and mechanical devices to mimic the effect of movement, such as alternating pressure mattresses. The most commonly used method of reducing the risk of pressure ulcers is regular nursing intervention and a 'turning schedule' to ensure the weight of the immobile patient is redistributed, reducing sustained pressure on a vulnerable area.
, bladder distension, osteomyelitis
, pyarthroses, sepsis
, amyloidosis
, anemia
, urethra
l fistula
, gangrene
and very rarely malignant transformation
(Marjolin's ulcer
- secondary carcinomas in chronic wounds). Sores often recur because patients do not follow recommended treatment or develop seroma
s, hematoma
s, infection
s, or dehiscence
. Paralytic
patients are the most likely people to have pressure sores recur. In some cases, complications from pressure sores can be life-threatening. The most common causes of fatality stem from renal failure
and amyloidosis
.
Decubitus
Commonly used in medicine, the word decubitus is used to mean "lying down". It is derived from the Latin verb “decumbere” meaning "to lie down"....
ulcers, are lesion
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
s caused by many factors—such as unrelieved pressure, friction, humidity, shearing forces, temperature, age, continence, and medication—to any part of the body, especially portions over bony
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
or cartilaginous
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...
areas such as sacrum
Sacrum
In vertebrate anatomy the sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...
, elbows, knees, and ankles. Although often prevented and treatable if found early, they can be very difficult to prevent in frail elderly patients, wheelchair users (especially where spinal injury is involved) and terminally ill patients. Bedsores are often fatal—even under the auspices of medical care—and are one of the leading iatrogenic causes of death reported in developed countries, second only to adverse drug reaction
Adverse drug reaction
An adverse drug reaction is an expression that describes harm associated with the use of given medications at a normal dosage. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs...
s. The primary cure and treatment is to remove the pressure by turning the patient regularly (every two hours is often quoted, though the evidence for this figure is not strong and four hourly turns may be as effective in some patients). However the relief of pressure to avoid further sores is well documented since at least the 19th century; regular turning was advised to prevent sores by Galloway (though some of her other recommendations are not current practice, for example massage of the pressure area is probably contra-indicated) and virtually all authors since.
Classification
The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP) in the United States. Briefly, however, they are as follows:- Stage I is the most superficial, indicated by non blanchable redness that does not subside after pressure is relieved. This stage is visually similar to reactive hyperemia seen in skin after prolonged application of pressure. Stage I pressure ulcers can be distinguished from reactive hyperemia in two ways: a) reactive hyperemia resolves itself within 3/4 of the time pressure was applied, and b) reactive hyperemia blanches when pressure is applied, whereas a Stage I pressure ulcer does not. The skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient. Although easy to identify on a light-skinned patient, ulcers on darker-skinned individuals may show up as shades of purple or blue in comparison to lighter skin tones.
- Stage II is damage to the epidermis extending into, but no deeper than, the dermisDermisThe dermis is a layer of skin between the epidermis and subcutaneous tissues, and is composed of two layers, the papillary and reticular dermis...
. In this stage, the ulcer may be referred to as a blisterBlisterA blister is a small pocket of fluid within the upper layers of the skin, typically caused by forceful rubbing , burning, freezing, chemical exposure or infection. Most blisters are filled with a clear fluid called serum or plasma...
or abrasion. - Stage III involves the full thickness of the skin and may extend into the subcutaneous tissueSubcutaneous tissueThe hypodermis, also called the hypoderm, subcutaneous tissue, or superficial fascia is the lowermost layer of the integumentary system in vertebrates. Types of cells that are found in the hypodermis are fibroblasts, adipose cells, and macrophages...
layer. This layer has a relatively poor blood supply and can be difficult to heal. At this stage, there may be undermining damage that makes the wound much larger than it may seem on the surface - Stage IV is the deepest, extending into the muscleMuscleMuscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
, tendonTendonA tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
or even boneBoneBones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
. A graphic presentation of severe stage IV ulcers is visible here. - Unstageable pressure ulcers are covered with dead cells, or escharEscharAn eschar is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds, and exposure to cutaneous anthrax....
and wound exudate,such that the depth cannot be determined.
Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
With higher stages, healing time is prolonged. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year. It is important to note that pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer).
Etiology
Bedsores are accepted to be caused by three different tissue forces:- Pressure, or the compression of tissues. In most cases, this compression is caused by the force of bone against a surface, as when a patient remains in a single decubitusDecubitusCommonly used in medicine, the word decubitus is used to mean "lying down". It is derived from the Latin verb “decumbere” meaning "to lie down"....
position for a lengthy period. After an extended amount of time with decreased tissue perfusionPerfusionIn physiology, perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. The word is derived from the French verb "perfuser" meaning to "pour over or through."...
, ischemiaIschemiaIn medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
occurs and can lead to tissue necrosisNecrosisNecrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
if left untreated.
- Shear force, or a force created when the skin of a patient stays in one place as the deep fasciaFasciaA fascia is a layer of fibrous tissue that permeates the human body. A fascia is a connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves, binding those structures together in much the same manner as plastic wrap can be used to hold the contents of sandwiches...
and skeletal muscleSkeletal muscleSkeletal muscle is a form of striated muscle tissue existing under control of the somatic nervous system- i.e. it is voluntarily controlled. It is one of three major muscle types, the others being cardiac and smooth muscle...
slide down with gravity. This can also cause the pinching off of blood vessels which may lead to ischemiaIschemiaIn medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
and tissue necrosisNecrosisNecrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
.
- Friction, or a force resisting the shearing of skin. This may cause excess shedding through layers of epidermis.
Aggravating the situation may be other conditions such as excess moisture from incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...
, perspiration or exudate
Exudate
An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. It can apply to plants as well as animals. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as sap or blood...
. Over time, this excess moisture may cause the bonds between epithelial cells to weaken thus resulting in the maceration of the epidermis. Temperature is also a very important factor. The cutaneous metabolic demand rises by 13% for every 1°C rise in cutaneous temperature. When supply can't meet demand, necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
therefore occurs. Other factors in the development of bedsores include age, nutrition, vascular disease, diabetes mellitus
Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
, and smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
, amongst others.
There are currently two major theories about the development of pressure ulcers. The first and most accepted is the deep tissue injury theory which claims that the ulcers begin at the deepest level, around the bone, and move outward until they reach the epidermis. The second, less popular theory is the top-to-bottom model which says that skin first begins to deteriorate at the surface and then proceeds inward.
Pathophysiology
Pressure ulcers may be caused by inadequate blood supply and resulting reperfusion injuryReperfusion injury
Reperfusion injury is the tissue damage caused when blood supply returns to the tissue after a period of ischemia or lack of oxygen. The absence of oxygen and nutrients from blood during the ischemic period creates a condition in which the restoration of circulation results in inflammation and...
when blood re-enters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
flow to affected areas. Within 2 hours, this shortage of blood supply, called ischemia
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
, may lead to tissue
Tissue (biology)
Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...
damage and cell
Cell (biology)
The cell is the basic structural and functional unit of all known living organisms. It is the smallest unit of life that is classified as a living thing, and is often called the building block of life. The Alberts text discusses how the "cellular building blocks" move to shape developing embryos....
death
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....
. The sore will initially start as a red, painful area, which eventually turns purple. Left untreated, the skin may break open and become infected
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
. Moist skin is more sensitive to tissue ischemia and necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
and is also more likely to get infected.
Epidemiology
Within acute care in the United States, the incidenceIncidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
of bedsores is 0.4% to 38%; within long-term care, 2.2% to 23.9%; and in home care, 0% to 17%. There is the same wide variation in prevalence
Prevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
: 10% to 18% in acute care, 2.3% to 28% in long-term care, and 0% to 29% in home care. There is a much higher rate of bedsores in intensive care units because of immunocompromised individuals, with 8% to 40% of ICU patients developing bedsores. However pressure ulcer prevalence is highly dependent on the methodology used to collect the data. Using the European Pressure Ulcer Advisory Panel (EPUAP) methodology there is are similar figures for pressure ulcers in acute hospital patients. There are differences across countries, but in Europe (for example) using this methodology pressure ulcer prevalence was consistently high, from 8.3% (Italy) to 22.9% (Sweden). A recent study in Jordan also showed a figure in this range.
The risk of developing bedsores can be determined by using the Braden Scale for Predicting Pressure Ulcer Risk
Braden Scale for Predicting Pressure Ulcer Risk
The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer...
.
Treatment
The best treatment outcomes will result from using a multidisciplinary team of specialists, this will ensure all problems are addressed.There are seven major contributors to healing.
Preventative care
The most important care for a patient with bedsores is the relief of pressure. Once a bedsore is found, pressure should immediately be lifted from the area and the patient turned at least every two hours to avoid aggravating the wound.Nursing home
Nursing home
A nursing home, convalescent home, skilled nursing unit , care home, rest home, or old people's home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living...
s and hospital
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
s usually set programs to avoid the development of bedsores in bedridden patients such as using a standing frame
Standing frame
A standing frame is assistive technology that can be used by a person who relies on a wheelchair for mobility...
to reduce pressure and ensuring dry sheets by using catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
s or impermeable dressings. For individuals with paralysis
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...
, pressure shifting on a regular basis and using a cushion featuring pressure relief components can help prevent pressure wounds.
Pressure-distributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. Antidecubitus mattresses and cushions can contain multiple air chambers that are alternately pumped. However, methods to evaluate the efficacy of these products have only been developed in recent years.
Debridement
The removal of necrotic tissue is an absolute must in the treatment of pressure sores. Because dead tissue is an ideal area for bacterial growth, it has the ability to greatly compromise wound healing. There are at least seven ways to excise necrotic tissue.- Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes. It is a slow process, but mostly painless.
- Biological debridement, or maggot debridement therapyMaggot therapyMaggot therapy is a type of biotherapy involving the intentional introduction of live, disinfected maggots into the non-healing skin and soft tissue wound of a human or animal for the purpose of cleaning out the...
, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria. Although this fell out of favour for many years, in January 2004, the FDA approved maggots as a live medical device. - Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue.
- Surgical debridement or Sharp Debridement is the most popular method, as it allows a surgeon to quickly remove dead tissue with little pain to the patient.
Infection control
Infection has one of the greatest effects on the healing of a wound. Symptoms of systemic infection include feverFever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
, pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
, redness
Erythema
Erythema is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin. It occurs with any skin injury, infection, or inflammation...
, swelling, warmth of the area, and purulent discharge
Pus
Pus is a viscous exudate, typically whitish-yellow, yellow, or yellow-brown, formed at the site of inflammatory during infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule or...
. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus.
In order to eliminate this problem, it is imperative to apply antiseptics at once. Hydrogen peroxide
Hydrogen peroxide
Hydrogen peroxide is the simplest peroxide and an oxidizer. Hydrogen peroxide is a clear liquid, slightly more viscous than water. In dilute solution, it appears colorless. With its oxidizing properties, hydrogen peroxide is often used as a bleach or cleaning agent...
is not recommended for this task as it is difficult to balance the toxicity of the wound with this. New dressings have been developed that have cadexomer iodine and silver in them, and they are used to treat bad infections. Duoderm
Duoderm
A hydrocolloid dressing is an opaque dressing used in medicine to provide a moist wound-healing environment, while protecting from contamination...
can be used on smaller wounds to both provide comfort and protect them from infection.
Systemic antibiotics are not recommended in treating infection of a bedsore, as it can lead to bacterial resistance.
Nutritional support
Upon admission the patient should have a consultation with a dietitianDietitian
Dietitians supervise the preparation and service of food, develop modified diets, participate in research, and educate individuals and groups on good nutritional habits. The goals of dietitians are to provide medical nutritional intervention, and to obtain, safely prepare, serve and advise on...
to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietitian should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check serum albumin
Serum albumin
Serum albumin, often referred to simply as albumin is a protein that in humans is encoded by the ALB gene.Serum albumin is the most abundant plasma protein in mammals. Albumin is essential for maintaining the osmotic pressure needed for proper distribution of body fluids between intravascular...
and lymphocyte
Lymphocyte
A lymphocyte is a type of white blood cell in the vertebrate immune system.Under the microscope, lymphocytes can be divided into large lymphocytes and small lymphocytes. Large granular lymphocytes include natural killer cells...
counts. Additionally, a bioelectrical impedance analysis
Bioelectrical impedance analysis
Bioelectrical impedance analysis is a commonly used method for estimating body composition. Since the advent of the first commercially available devices in the mid-1980s the method has become popular owing to its ease of use, portability of the equipment and its relatively low cost compared to...
should be considered.
If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with dietary supplements and nutrients including, but not limited to, arginine
Arginine
Arginine is an α-amino acid. The L-form is one of the 20 most common natural amino acids. At the level of molecular genetics, in the structure of the messenger ribonucleic acid mRNA, CGU, CGC, CGA, CGG, AGA, and AGG, are the triplets of nucleotide bases or codons that codify for arginine during...
, glutamine
Glutamine
Glutamine is one of the 20 amino acids encoded by the standard genetic code. It is not recognized as an essential amino acid but may become conditionally essential in certain situations, including intensive athletic training or certain gastrointestinal disorders...
, vitamin A
Vitamin A
Vitamin A is a vitamin that is needed by the retina of the eye in the form of a specific metabolite, the light-absorbing molecule retinal, that is necessary for both low-light and color vision...
, vitamin B complex, vitamin E
Vitamin E
Vitamin E is used to refer to a group of fat-soluble compounds that include both tocopherols and tocotrienols. There are many different forms of vitamin E, of which γ-tocopherol is the most common in the North American diet. γ-Tocopherol can be found in corn oil, soybean oil, margarine and dressings...
, vitamin C
Vitamin C
Vitamin C or L-ascorbic acid or L-ascorbate is an essential nutrient for humans and certain other animal species. In living organisms ascorbate acts as an antioxidant by protecting the body against oxidative stress...
, magnesium
Magnesium
Magnesium is a chemical element with the symbol Mg, atomic number 12, and common oxidation number +2. It is an alkaline earth metal and the eighth most abundant element in the Earth's crust and ninth in the known universe as a whole...
, manganese
Manganese
Manganese is a chemical element, designated by the symbol Mn. It has the atomic number 25. It is found as a free element in nature , and in many minerals...
, selenium
Selenium
Selenium is a chemical element with atomic number 34, chemical symbol Se, and an atomic mass of 78.96. It is a nonmetal, whose properties are intermediate between those of adjacent chalcogen elements sulfur and tellurium...
and zinc
Zinc
Zinc , or spelter , is a metallic chemical element; it has the symbol Zn and atomic number 30. It is the first element in group 12 of the periodic table. Zinc is, in some respects, chemically similar to magnesium, because its ion is of similar size and its only common oxidation state is +2...
. It is very important that intake of these vitamins and minerals be overseen by a physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
, as many of them can be detrimental in incorrect dosages.
There is anecdotal evidence that high protein diet helps healing of sores. High protein diet seems to be especially helpful in sores that do not heal in eight weeks.
Educating the caregiver
In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one's pressure ulcers. The cross-specialization wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things.As this is a very difficult undertaking, the caregiver may feel overburdened and depressed, so it may be best to bring in a psychological consult.
Wound intervention
Once the patient has reached the point that intervention is possible, there are many different options. For patients with Stages I and II ulcers, the wound care team should use guidelines established by the American Medical Directors Association (AMDA) for the treatment of these low-grade sores.For those with Stage III or IV ulcers, most interventions will likely include surgery such as a tissue flap, free flap or other closure methods. A more recent intervention is Negative Pressure Wound Therapy
Negative Pressure Wound Therapy
Negative-pressure wound therapy is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of first and second degree burns. The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment, using a...
, which is the application of topical negative pressure to the wound. This technique, developed by scientists at Wake Forest University
Wake Forest University
Wake Forest University is a private, coeducational university in the U.S. state of North Carolina, founded in 1834. The university received its name from its original location in Wake Forest, north of Raleigh, North Carolina, the state capital. The Reynolda Campus, the university's main campus, is...
, uses foam placed into the wound cavity which is then covered in a film which creates an airtight seal. Once this seal is established, the technician is able to remove exudate and other infectious materials in addition to aiding the body produce granulation tissue, the best bed for the creation of new skin.
There are, unfortunately, contraindication
Contraindication
In medicine, a contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment.Some contraindications are absolute, meaning that there are no reasonable circumstances for undertaking a course of action...
s to the use of negative pressure therapy. Most deal with the unprepared patient, one who has not gone through the previous steps toward recovery, but there are also wound characteristics that bar a patient from participating: a wound with inadequate circulation
Circulatory system
The circulatory system is an organ system that passes nutrients , gases, hormones, blood cells, etc...
, a raw debrided wound, a wound with necrotised tissue and eschar
Eschar
An eschar is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds, and exposure to cutaneous anthrax....
, and a fibrotic
Fibrosis
Fibrosis is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process. This is as opposed to formation of fibrous tissue as a normal constituent of an organ or tissue...
wound.
After Negative Pressure Wound Therapy
Negative Pressure Wound Therapy
Negative-pressure wound therapy is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of first and second degree burns. The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment, using a...
, the patient should be reevaluated every two weeks to determine future therapy.
Prevention
It is common sense that prevention is better than cure - this applies particularly to pressure sores, which are painful and slow to heal, and most of which are definitely preventable if good clinical practice is followed. In the UK the Royal College of NursingRoyal College of Nursing
The Royal College of Nursing is a union membership organisation with over 395,000 members in the United Kingdom. It was founded in 1916, receiving its Royal Charter in 1928, Queen Elizabeth II is the patron...
has published guidelines in 'Pressure ulcer risk assessment and prevention'. It is important to identify those who are at risk and to intervene early with strategies for prevention, in the bed, wheelchair or chair, in the bath and on the commode - indeed, it is a requirement within the National Standards for Care Homes (UK) to do so:
"Standard 8.3 Service users are assessed, by a person trained to do so, to identify those service users who have developed, or are at risk of developing, pressure sores and appropriate intervention is recorded in the plan of care.
8.4 The incidence of pressure sores, their treatment and outcome, are recorded in the service user’s individual plan of care and reviewed on a continuing basis.
8.5 Equipment necessary for the promotion of tissue viability and prevention or treatment of pressure sores is provided."
A wide variety of techniques are used to mitigate the risk of pressure ulcers in at risk groups including: nutritional supplements, topical skin protection and mechanical devices to mimic the effect of movement, such as alternating pressure mattresses. The most commonly used method of reducing the risk of pressure ulcers is regular nursing intervention and a 'turning schedule' to ensure the weight of the immobile patient is redistributed, reducing sustained pressure on a vulnerable area.
Complications
Pressure sores can trigger other ailments, cause patients considerable suffering, and be expensive to treat. Some complications include autonomic dysreflexiaAutonomic dysreflexia
Autonomic dysreflexia, "AD" also known as "autonomic hyperreflexia or Hyperreflexia, is a potentially life threatening condition which can be considered a medical emergency requiring immediate attention. AD occurs most often in spinal cord-injured individuals with spinal lesions above the T6 spinal...
, bladder distension, osteomyelitis
Osteomyelitis
Osteomyelitis simply means an infection of the bone or bone marrow...
, pyarthroses, sepsis
Sepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
, amyloidosis
Amyloidosis
In medicine, amyloidosis refers to a variety of conditions whereby the body produces "bad proteins", denoted as amyloid proteins, which are abnormally deposited in organs and/or tissues and cause harm. A protein is described as being amyloid if, due to an alteration in its secondary structure, it...
, anemia
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
, urethra
Urethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
l fistula
Fistula
In medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Locations:Fistulas can develop in various parts of the...
, gangrene
Gangrene
Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies . This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood...
and very rarely malignant transformation
Malignant transformation
Malignant transformation is the process by which cells acquire the properties of cancer. This may occur as a primary process in normal tissue, or secondarily as malignant degeneration of a previously existing benign tumor....
(Marjolin's ulcer
Marjolin's ulcer
Marjolin's ulcer refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized, chronically inflamed, or scarred skin...
- secondary carcinomas in chronic wounds). Sores often recur because patients do not follow recommended treatment or develop seroma
Seroma
A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....
s, hematoma
Hematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
s, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
s, or dehiscence
Wound dehiscence
Wound dehiscence is a surgical complication in which a wound breaks open along surgical suture. Risk factors are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery.-Symptoms:...
. Paralytic
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...
patients are the most likely people to have pressure sores recur. In some cases, complications from pressure sores can be life-threatening. The most common causes of fatality stem from renal failure
Renal failure
Renal failure or kidney failure describes a medical condition in which the kidneys fail to adequately filter toxins and waste products from the blood...
and amyloidosis
Amyloidosis
In medicine, amyloidosis refers to a variety of conditions whereby the body produces "bad proteins", denoted as amyloid proteins, which are abnormally deposited in organs and/or tissues and cause harm. A protein is described as being amyloid if, due to an alteration in its secondary structure, it...
.