Bedsores or Pressure Ulcers: How does it occur?

 

 

Bedsores are also referred to as pressure ulcers or decubitus ulcers, (Decubitus refers to a patient’s position in bed) or pressure ulcers. An ulcer is a break in the continuity of the epithelium. Bedsores refer to broken areas of the epidermis as a result of pressure atrophy. Due to increased pressure on the skin by the underlying muscle and bones, the skin undergoes atrophy. If the injurious stimuli (in this case, sustained pressure), it may compromise the blood supply and nervous supply to the skin. As a result, there is localized atrophy. It may lead to ulceration of the underlying bone on the surface of the skin if the pressure is chronic.

Bedsores: Who is at increased risk?

Bedsores are common in patients who are cared for in hospitals for prolonged periods or in nursing homes where patients are generally confined to bed. They are seen in people who have the following risk factors:

1. Age above 85 years. The skin is fragile and more prone to ulceration.
2. Malnutrition may also lead to the development of bedsores due to the deficiency of essential minerals and vitamins required for normal wear and tear of the body.
3. In persons with compromised blood supply as in different forms of vasculitis, atherosclerosis and diabetic microangiopathies, the blood supply is reduced. This makes the skin more vulnerable to pressure changes.
4. Diabetic patients also have an increased risk of developing pressure sores due to neuropathy. There is diminished sensation of pain at the pressure site (Pain is a protective response which makes the body aware of an injurious stimulus. As a result, we tend to avoid the pain by altering the body posture/decubitus)
5. Decreased mobility in patients receiving ambulatory care predisposes them to pressure ulcers. This is because there is a diminished supply of oxygenated blood and nutrients, making them more liable for the injury.
6. Increased perspiration, urinary or faecal incontinence which leads to moist skin, also lead to infection and further skin injury. It is complicated by the friction of the body surface against the bed.
7. Shearing forces in the opposite direction exert a pull and push effect. This may also lead to tears and bed sores.

The common site of bedsores is dependent on the position or the lie of the patient in the bed.

In supine patients, heel, ankle, hip, buttocks and shoulder blade are more prone to undergo pressure atrophy and subsequently develop into pressure ulcers.

In wheelchair bound patients, the shoulder blade, heel and ball of the foot are more likely to develop pressure sores.

The symptoms of an impending bedsore include:

• An unusually warm or cool area of the body to touch.
• Swelling over the site
• Purulent discharge
• Tenderness and Pain

The 4 stages of a bedsore are as follows:

Bedsores Complications:

1. Cellulitis is characterized by superficial skin and subcutaneous inflammation. It is characterized by warmth, tenderness, and swelling.
2. The infection may burrow deep and lead to underlying joint damage (septic arthritis) or may lead to bone infection (osteomyelitis) with a discharging sinus filled with pus.
3. Chronic non-healing venous ulcers, also known as Marjolin’s ulcers may turn malignant and lead to squamous cell carcinoma of the skin.

bedsores Diagnosis and Treatment:

A bedsore is usually diagnosed clinically. However, a number of haematological investigations, especially a complete blood count and a differential leucocyte count may be advised to check for local or systemic infection. Additionally, any discharge may be sent to microbiology testing for identifying the organism and accordingly starting appropriate antibiotic therapy (oral or intravenous)

The treatment depends upon the stage of the ulcer. Stage 1 bedsores are usually covered with a protective pad or lubricant to prevent further friction. Stage 2 ulcers generally require wound dressing (including saline wash, topical povidone-iodine, and antibiotic prophylactic antibiotics. Larger areas of dead tissue may be trimmed away surgically or require treatment with a sloughing agent such as hydrogen peroxide. Deep craters and exposed ulcers may need skin grafting and flap reconstruction surgery.

Bedsore Prevention:

Advice for re-positioning

For bedridden patients, one must ask them to frequently change positions every hour. If possible, they must be asked to lift their body from the bed on their own.

Special wheelchairs that allow for tilt adjustment along with comfortable cushion/mattresses relieve the pressure.

In order to prevent shearing, commonly head elevation is advised.

The skin must be inspected daily to look for warning signs of an impending ulcer. It must be routinely cleansed and kept dry, free of moisture. Application of powder at friction points or lotion/moisturizer to dry skin also helps to keep the skin healthy.