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Basics About Bedsores


I just accepted two new bedsore cases.  One is in Nashville, Tennessee, and the other is in Dickson, Tennessee.  In many of these cases, the nursing home’s defense attorneys and paid witnesses state that the wounds were unavoidable.  They commonly ignore issues like what the standard of care required the caregivers to do for the resident and that the caregivers failed to meet the standard of care.  Those pesky little issues are overlooked and they argue something along the lines of “well even if we had done everything we were supposed to do, the wounds would have still developed as they were unavoidable.”  In my opinion, that is an intellectually dishonest attempt to avoid responsibility.  Let’s look at the big picture. 

The Mayo Clinic agrees that bedsores are easier to prevent than to treat.  Bedsore cases are tragic – and, unfortunately, they are all too common.  Bedsores — also called pressure sores or pressure ulcers — are injuries to skin and underlying tissue resulting from prolonged, often unrelieved, pressure on the skin.  Bedsores most often develop on skin that covers the boniest areas of the body, most commonly the heels, ankles, hips and tailbone.  Bedsores are caused by pressure against the skin that limits blood flow to the skin and nearby tissues. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores. Three primary contributing factors are:

  • Sustained pressure. When the resident or patient’s skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or a bed, the pressure may be greater than the pressure of the blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to tissues. Without these essential nutrients, skin cells and tissues are damaged and may eventually die.?This kind of pressure tends to happen in areas that aren't well-padded with muscle or fat and that lie over a bone, such as the resident or patient’s spine, tailbone, shoulder blades, hips, heels and elbows.
  • Friction. Friction is the resistance to motion. It may occur when the skin is dragged across a surface, such as when the resident or patient changes position or a care provider moves them. The friction may be even greater if the skin is moist. Friction may make fragile skin more vulnerable to injury.

Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a hospital bed is elevated at the head, the resident or patient can slide down in bed. As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction. This motion may injure tissue and blood vessels, making the site more vulnerable to damage from sustained pressure.

 

Nursing home residents and hospital patients are most at risk of bedsores as they commonly have medical conditions that limit their ability to change positions, require them to use a wheelchair or confine them to a bed for a long time.

Bedsores can develop quickly and are often difficult to treat.

 

Bedsores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization that promotes the prevention and treatment of pressure ulcers, defines each stage as follows:

Stage I

The beginning stage of a pressure sore has the following characteristics:

  • The skin is not broken.
  • The skin appears red on people with lighter skin color, and the skin doesn't briefly lighten (blanch) when touched.
  • On people with darker skin, the skin may show discoloration, and it doesn't blanch when touched.
  • The site may be tender, painful, firm, soft, warm or cool compared with the surrounding skin.

Stage II

At stage II:

  • The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost.
  • The wound may be shallow and pinkish or red.
  • The wound may look like a fluid-filled blister or a ruptured blister.

Stage III

At stage III, the ulcer is a deep wound:

  • The loss of skin usually exposes some fat.
  • The ulcer looks crater-like.
  • The bottom of the wound may have some yellowish dead tissue.
  • The damage may extend beyond the primary wound below layers of healthy skin.

Stage IV

A stage IV ulcer shows large-scale loss of tissue:

  • The wound may expose muscle, bone or tendons.
  • The bottom of the wound likely contains dead tissue that's yellowish or dark and crusty.
  • The damage often extends beyond the primary wound below layers of healthy skin.

 

Common sites of pressure sores

Pressure sores often occur on skin over the following sites:

  • Tailbone or buttocks
  • Shoulder blades and spine
  • Backs of arms and legs where they rest against the chair
  • Back or sides of the head
  • Rim of the ears
  • Shoulders or shoulder blades
  • Hip, lower back or tailbone
  • Heels, ankles and skin behind the knees

 

 

Risk factors for pressure sores

People are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to:

  • Generally poor health or weakness
  • Paralysis
  • Injury or illness that requires bed rest or wheelchair use
  • Recovery after surgery
  • Sedation
  • Coma

Other factors that increase the risk of pressure sores include:

  • Age. The skin of older adults is generally more fragile, thinner, less elastic and drier than the skin of younger adults. Also, older adults usually produce new skin cells more slowly. These factors make skin vulnerable to damage.
  • Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of bedsores or the need to change position.
  • Weight loss. Weight loss is common during prolonged illnesses, and muscle atrophy and wasting are common in people with paralysis. The loss of fat and muscle results in less cushioning between bones and a bed or a wheelchair.
  • Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.
  • Excess moisture or dryness. Skin that is moist from sweat or lack of bladder control is more likely to be injured and increases the friction between the skin and clothing or bedding. Very dry skin increases friction as well.
  • Bowel incontinence. Bacteria from fecal matter can cause serious local infections and lead to life-threatening infections affecting the whole body.
  • Medical conditions affecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage.
  • Smoking. Smoking reduces blood flow and limits the amount of oxygen in the blood. Smokers tend to develop more-severe wounds, and their wounds heal more slowly.
  • Limited alertness. People whose mental awareness is lessened by disease, trauma or medications may be unable to take the actions needed to prevent or care for pressure sores.

Muscle spasms. People who have frequent muscle spasms or other involuntary muscle movement may be at increased risk of pressure sores from frequent friction and shearing.

 

Complications of pressure ulcers include:

  • Sepsis. Sepsis occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure.
  • Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. Cellulitis can lead to life-threatening complications.
  • Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications.

Cancer. Another complication is the development of a type of squamous cell carcinoma that develops in chronic, nonhealing wounds (Marjolin ulcer). This type of cancer is aggressive and usually requires surgery.

 

Reducing pressure

The first step in treating a bedsore is reducing the pressure that caused it. Strategies include the following:

  • Repositioning. If the resident or patient has a pressure sore, they need to be repositioned regularly and placed in correct positions.  If the resident or patient uses a wheelchair, weight should be shifted at least every 15 minutes. If the resident or patient is confined to a bed, they should change positions every two hours.?
  • Using support surfaces. A mattress, bed and special cushions that help the resident or patient lie in an appropriate position, relieve pressure on any sores and protect vulnerable skin should be used. If the resident or patient is in a wheelchair, a cushion should be used.

Cleaning and dressing wounds

Care that helps with healing of the wound includes the following:

  • Cleaning. It's essential to keep wounds clean to prevent infection. If the affected skin is not broken (a stage I wound), gently wash it with water and mild soap and pat dry. Clean open sores with a saltwater (saline) solution each time the dressing is changed.
  • Applying dressings. A dressing promotes healing by keeping a wound moist, creating a barrier against infection and keeping the surrounding skin dry. Dressing choices include films, gauzes, gels, foams and treated coverings. A combination of dressings may be used.?  A doctor selects a dressing based on a number of factors, such as the size and severity of the wound, the amount of discharge, and the ease of placing and removing the dressing.

Removing damaged tissue

To heal properly, wounds need to be free of damaged, dead or infected tissue.  Removing this tissue (debridement) is accomplished with a number of methods, depending on the severity of the wound, the resident or patient’s overall condition and the treatment goals.

  • Surgical debridement involves cutting away dead tissue.
  • Mechanical debridement loosens and removes wound debris. This may be done with a pressurized irrigation device, low-frequency mist ultrasound or specialized dressings.
  • Autolytic debridement enhances the body's natural process of using enzymes to break down dead tissue. This method may be used on smaller, uninfected wounds and involves special dressings to keep the wound moist and clean.
  • Enzymatic debridement involves applying chemical enzymes and appropriate dressings to break down dead tissue.

Other interventions

Other interventions that may be used are:

  • Pain management. Pressure ulcers can be painful. Nonsteroidal anti-inflammatory drugs — such as ibuprofen (Motrin IB, Advil, others) and naproxen (Aleve, others) — may reduce pain. These may be very helpful before or after repositioning, debridement procedures and dressing changes. Topical pain medications also may be used during debridement and dressing changes.
  • Antibiotics. Infected pressure sores that aren't responding to other interventions may be treated with topical or oral antibiotics.
  • A healthy diet. To promote wound healing, the resident or patient’s doctor or dietitian may recommend an increase in calories and fluids, a high-protein diet, and an increase in foods rich in vitamins and minerals.
  • Management of incontinence. Urinary or bowel incontinence may cause excess moisture and bacteria on the skin, increasing the risk of infection.
  • Muscle spasm relief. Spasm-related friction or shearing can cause or worsen bedsores. Muscle relaxants — such as diazepam (Valium), tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen (Gablofen, Lioresal) — may inhibit muscle spasms and help sores heal.
  • Negative pressure therapy (vacuum-assisted closure, or VAC). This therapy uses a device that applies suction to a clean wound. It may help healing in some types of pressure sores.

Surgery

A pressure sore that fails to heal may require surgery.  The goals of surgery include improving the hygiene and appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of cancer.

If a resident or patient needs surgery, the type of procedure depends mainly on the location of the wound and whether it has scar tissue from a previous operation.  In general, most pressure sores are repaired using a pad of muscle, skin or other tissue to cover the wound and cushion the affected bone (called flap reconstruction).

 

 

If you or a loved one has suffered from an injury caused by a nursing home, please call my office for a free consultation.

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