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Bedsores (pressure sores)

Definition


Disease: Bedsores (pressure sores) Bedsores (pressure sores)
Category: Dermatological diseases
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Disease Definition:

Pressure sores, also called pressure ulcers or bedsores, are areas of damaged skin and tissue that develop when circulation is cut off by sustained pressure to vulnerable parts of the body, such as the skin on the heels, hips and buttocks. The affected tissue will die without adequate blood flow.

Bedsores can develop especially in people living with paralysis, in addition to people who use wheelchair, are bedridden or are unable to change positions without help.

These bedsores are usually difficult to heal; they develop quickly and progress rapidly. However, health experts say that these wounds don’t have to occur. Preventive measures can encourage healing of bedsores and maintain the skin’s integrity.

Work Group:


Prepared by: Scientific Section

Symptoms, Causes

Symptoms:

Based on their severity, bedsores fall into one of four stages. Those four stages are defined as:

STAGE 1:
A pressure sore usually begins as a persistent area of red skin that may itch and feel firm to the touch or warm, spongy and painful. However, the mark could appear to have a purple or blue cast or even look flaky or ashen in Hispanics, blacks, and other people with darker skin. Usually, the wounds in this stage are superficial and shortly after the pressure is relieved, they go away.

STAGE 2:
Some sort of skin loss has already occurred by this stage, either in both the deeper layer of the skin called the dermis and the outermost layer called the epidermis, or in just one of them. By this stage, the surrounding tissues of the wound could show red or purple discoloration, and the wound itself will be an open sore, which looks like a blister or an abrasion.

STAGE 3:
In this stage, the damage extends to the tissue below the skin and creates a wound that is deep and crater-like.

STAGE 4:
In this stage, a large-scale loss of skin occurs, as well as damage to underlying muscle, bone and supporting structures, such as joints and tendons. This is the most serious and advanced stage.

In case someone uses a wheelchair, they will probably develop pressure sores on:

  • The backs of their legs and arms, where they rest against the chair.
  • Their tailbone or buttocks
  • The shoulder blades and spine


In case someone is bed-bound, they will probably develop pressure sores on:

  • The backs or sides of their ankles, knees, toes and heels
  • The rims of their ears
  • Their lower back or tailbone and hipbones
  • The sides or back of their head
  • Their shoulder blades or shoulders


In case someone notices any open sores or broken skin, they should contact their doctor. However, if these sores develop signs of infection, such as a foul odor, increased heat and redness in the surrounding skin, fever or drainage from the sore, they should get immediate medical care.

Causes:

Every day people, without thinking, make hundreds of subtle postural adjustments, such as turn a dozen times in their sleep, shift in their chair during meeting and fiddle with the radio when driving. These postural adjustments help avoid problems that arise from inactivity. However, for immobilized people by illness, injury or paralysis, these problems, such as bedsores, are a constant threat.

Bedsores can be caused by several factors when someone is immobilized, such as:

Friction:
The key to prevent bedsores is the frequent shifting in position. However, when someone simply turns from one side to another, the friction that happens during this process can damage their skin, making it more susceptible to pressure sores.

Shear:
When someone's skin moves in one direction and the underlying bone in another, shear occurs. The tailbone is one of the commonly affected areas, because the skin is already thin and fragile. This could happen when someone slides down in a chair or bed or when they raise the head of their bed more than 30 degrees, causing cell walls and tiny blood vessels to stretch and tear.

Sustained pressure:
Blood flow gets restricted when someone's skin and the underlying tissues are trapped between bone and a surface, such as a bed or a wheelchair. Because of this restriction, tissue is deprived of oxygen and other nutrients, which can cause irreversible damage and tissue death. This usually occurs on the tailbone (coccyx), spine, elbows, shoulder blades, heels and hips, which are areas that aren’t well padded with muscle or fat and lie just over a bone.
Pressure that cuts off circulation can sometimes come from unlikely sources, such as perspiration, which can soften the skin and make it more vulnerable to injury, wrinkled clothing or sheets, rivets and thick seams in jeans, crumbs in the bed or a chair, whose tilt is slightly off.
 

Complications

Complications:

Serious or life-threatening infections of the muscle, bone or skin can’t be prevented even with the most conscientious care. Some of the complications that may be caused by bedsores are:

Cancer:
The skin’s squamous cells could be affected by an aggressive carcinoma.

Cellulitis:
Pain, redness and swelling, which can be severe, are caused by this acute infection of the skin’s connective tissue. This condition can also cause some life-threatening complications, such as sepsis and meningitis, which is the infection of the membrane and fluid surrounding the brain and spinal cord.

Sepsis:
This is a rapidly progressing and life-threatening condition that can cause shock and organ failure. It occurs when bacteria enters the bloodstream through the broken skin and spreads throughout the body. This condition is one of the greatest dangers of an advanced pressure sore.

Bone and joint infections:
When the infection from a bedsore burrows deep into the joints and bones, these infections develop. Bone infections (osteomyelitis) could reduce the function of the joints and limbs, while joint infections (septic or infectious arthritis) could damage cartilage and tissue.
 

Treatments:

Open wounds are slow to heal, and because skin and other tissues are already damaged or destroyed, healing is never perfect, which makes treating bedsores a challenge.

A multidisciplinary approach is required in addressing the many aspects of wound care, including emotional issues. The patient will receive care from nurses and their primary care physician together with a physical therapist and a social worker. They may also see a gastroenterologist or an urologist if incontinence is an issue. Also, a neurosurgeon, plastic surgeon and orthopedic surgeon will be involved in their care if their wound requires surgical repair.


CONSERVATIVE TREATMENTS:
Even though most stage 1 and 2 sores will heal within weeks with conservative measures, however, stage 3 and 4 wounds might require surgery, because they are less likely to resolve on their own.


Relieving the pressure that caused the sore is the first step of treating it. This pressure can be reduced by:

Using support surfaces:
In order to relieve pressure on an existing sore and to help protect vulnerable areas from further breakdown, a person should use special cushions, mattresses, pads and beds.

No one support surface is appropriate for all people or all situations, and the most effective support depends on many factors, including the person's level of mobility, their body build and the severity of the wound. For example, although sheepskin is helpful for separating parts of the body and preventing friction damage, however, it’s not thick enough to reduce pressure.

A person should avoid using pillows and rubber rings because they cause compression. However, they can use a variety of foam, water-filled or air-filled devices to cushion a wheelchair.

Low-air-loss beds or air-fluidized beds are usually suggested for mattresses. These low-air-loss beds use inflatable pillows for support, while air-fluidized beds suspend the person on an air-permeable mattress containing millions of silicone-coated beads.

Changing positions often:
When someone's in a wheelchair, they should turn and change their position approximately every 15 minutes, and when they're in bed, at least once every two hours. To help prevent friction when moving, they should use sheepskin or other padding over the wound. They should also ask the help of their caregiver in case they're unable to change positions by themselves.

Some of the other nonsurgical treatments for pressure sores are:

Cleaning:
To prevent infection, it is vital to keep the wounds clean. Although stage 1 wounds can be gently washed with water and mild soap, however, open sores must be cleaned with saline (saltwater) solution each time the dressing is changed. Hydrogen peroxide and iodine can damage sensitive tissue and delay healing, so they should be avoided.

In order to help sores heal, incontinence should be controlled as much as possible. Lifestyle changes, incontinence pads, medications or behavioral programs can help in case a person is experiencing bladder or bowel problems.


Debridement (removal of damaged tissue):
Wounds need to be free of damaged, dead or infected tissue in order to heal properly. The best approach depends on the person's treatment goals, the type of the wound and their overall condition.

One of these approaches is surgical debridement, which involves using a scalpel or another instrument to remove dead tissue. Although surgical debridement can be painful, but it is quick and effective. One or more nonsurgical approaches could be used, such as removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), which allows the body’s own enzymes to break down dead tissue (autolytic debridement), or applying topical debriding enzymes (enzymatic debridement).

Dressings:
To speed healing and help protect wounds, a variety of dressings are used. Usually, the type of dressing depends on the stage and severity of the wound. However, keeping the wound moist and the skin surrounding it dry is the basic approach. Contaminated sores could be treated with a topical antibiotic cream. Stage 1 sores might not need any covering, but stage 2 sores are usually treated with hydrocolloids, or transparent semipermeable dressings that retain moisture and encourage skin cell growth. In case someone develops wounds with surface debris or weeping wounds, other types of dressings could be more beneficial.

Oral antibiotics:
Someone may be prescribed oral antibiotics in case their pressure sores are infected.

Hydrotherapy:
By removing dead or contaminated tissue and keeping the skin clean, whirlpool baths can aid in the healing process.

Muscle spasm relief:
In order to help alleviate spasticity, a person may be recommended skeletal muscle relaxants that block nerve reflexes in their spine or in the muscle cells themselves. This is essential for both preventing and treating pressure sores.

Healthy diet:
To improve wound healing, a person should eat a nutritionally reach diet with adequate calories and protein and a full range of vitamins and minerals, particularly vitamin C and zinc. Being well nourished also protects the integrity of the skin and guards against breakdown. A person may be prescribed vitamin C and zinc supplements if they're at risk of or recovering from a pressure sore.

SURGICAL REPAIR:
Bedsores could reach a point where they require surgical intervention, even with the best medical care. Improving the hygiene and appearance of the sore, reducing fluid loss through the wound, lowering the risk of future cancer and treating infection are some of the goals of surgery.

The best type of reconstruction for the patient will depend on the location of their wound and whether there’s scar tissue from a previous operation. However, using a pad of muscle, skin or other tissue that covers the wound and cushions the affected bone (flap reconstruction) is how most pressure wounds are repaired. Usually, the tissue is harvested from the patient's own body. The wound is debrided before the operation, but much more extensively than it is in nonsurgical treatments.


More effective bedsore treatments are being searched. Hyperbaric oxygen, topical use of human growth factors and electrotherapy are under investigation. However, the only therapy that appears promising so far in early trials is the human growth factors, but further studies are still necessary.

Prognosis:

Not available

Expert's opinion

Expert's Name:
Certificate:
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Expert's opinion:

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Clinical Trials:

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