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Bedsores (pressure ulcers)

 Causes
 Risk group
 Symptoms
 Location
 Where to seek help and advice
 Treatment
Prevention


Causes

The cause of pressure ulcers (also called bedsores, decubitus ulcers or pressure sores) is tissue ischemia due to the prolonged pressure evoked on veins and arteries.

The risk of pressure ulcers depends on the duration of the pressure – the longer the pressure  is present  or the greater the force, the greater the possibility of developing bedsores.

In healthy people prolonged pressure causes pain forced to change position.

Unconscious and immobile people are not able to relieve the pressure automatically and to improve the blood circulation, thus they belong to the group of people at increased risk of pressure ulcer development.

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Pathomechanism of developing bedsores:

  • simple pressure i.e. the pressure exerted on the soft tissue on one side by the bone, and on the other by a hard surface
  • rubbing the patient’s body surface over bed linen e.g. when using improper technique for changing positions
  • lateral tensile forces, which act directly on the patient’s body

Risk group

The risk of developing pressure ulcers should be considered in all patients with long-term reduction of capacity for self-movement, which spend most of their time in bed or in a wheelchair.

Factors that increase the risk of pressure ulcer development are:

  • age
  • weight
  • nutritional status
  • sphincter function of the urethra and the anus
  • state of consciousness
  • diabetes, atherosclerosis
  • steroid therapy

Symptoms

Pressure ulcers are classified according to the severity of the symptoms into 4 or 5 degrees. And hence:

  • Stage I: intact skin with non-blanchable redness of a localised area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Microcirculation is not damaged yet.
  • Stage II: partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Presents as a shiny or dry shallow ulcer without slough or bruising.

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  • Stage III: abrasions, cracking skin and full-thickness skin damage to the border of the subcutaneous tissue, blisters, the wound edges are well marked out, surrounded by edema and erythemaOdleżyny_html_mb71a5da
  • Stage IV: the damage extends towards the subcutaneous fatty tissue; the ulceration can be free from infection and necrosis and covered with clear granulation tissue, but the necrosis may also affect the fatty tissue and the surrounding skin layers. The bottom may be covered with black necrosis.
  • Stage V: the presence of advanced necrosis, which extends towards the fascia and muscles; the damage can also affect joints and bones – unpleasant odour and profuse pus-necrotic discharge; in the wound there are pieces black dead tissue and black necrosis

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Location

Bedsores occur in places where the distance between bone prominence and the skin surface is the smallest i.e.  in contact point of the skin and the ground, where the pressure is the highest. Most pressure ulcers are formed around the aitchbone, coccyx, buttocks, on the heels or the hips.

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The above figures present the point of contact of the skin with the surface at various positions of the patient laying on the bed.

Where to seek help and advice

Of course, in the first place consult the general practitioner.

The treatment of pressure ulcers is the responsibility of a doctor and a nurse who has completed a specialist course in the treatment of chronic wounds. The competences of nurses are limited to the treatment of pressure 1 to 3 degree sores.

Sometimes the condition of the wound requires surgical debridement and then the GP directs us to a specialist surgeon.

The treatment of pressure ulcers is tough and long-lasting so to make it the least expensive and effective it must be based on genuine and systematic cooperation of the doctor and the patient, and must be combined with an intensive, professional care.

Treatment

First of all the treatment should be conducted under the supervision of a doctor or a nurse.

Bedsores are treated locally i.e. the wound is to be secured with dressings appropriate.

A very important part of treatment is also appropriate patient care, which include:

  • position changing – the patient should not lie on the bedsore
  • placing patient on a pressure relief mattress
  • protecting sore places with special anti-bedsore discs and stands
  • adequate nutrition and hydration of the patient
  • controlling comorbidities

The most effective form of treatment is the use of specially designed wound dressings for this purpose, the so-called specialised or advanced dressings that create a moist wound healing environment.

Choosing the right, effective dressing it must be based on a correct diagnosis of the processes occurring in the wound. To make it easier, you can use the wound colour classification matrix, which is based on the observation of the phenomena that take place in different phases of healing.

Wound colour classification matrix:

Macierz kolorowej klasyfikacji ran

Black wounds

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Wounds with black necrosis require:

  • maintaining a moist environment
  • removal of necrotic tissue in order to initiate the healing process

The healing process will not occur under thick layers of necrotic tissue; to begin it first the necrosis needs to be removed. We have a choice of two basic ways to get rid of the necrosis from the wound bed:

  • surgical debridement – the mechanical removal of necrotic tissue to expose healthy skin structures for initiating the process of wound healing
  • application of interactive dressings – involves the application of dressing on a wound, which stimulates the autolysis process i.e. the natural wound cleansing by the body. In this case the necrosis decomposition is made by enzymes produced by the damaged wound cells.

Recommended dressings for black wounds:

Yellow wounds

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Wounds with yellow, colliquative necrotic tissue require:

  • maintaining a moist environment
  • absorbing excess exudate, along with the remnants of necrotic material

Wounds with colliquative necrosis are characterised by an increased exuding level. The necrosis on the bottom of the wound is liquid. Such wounds provide an ideal environment for the growth of microorganisms, and therefore they are often infected. The tasks for the dressing in this case is the absorption of exudate and necrotic material, liquefaction of too dry and too dense necrosis, protection against drying out and against secondary injuries.

Recommended dressings for yellow wounds (depending on the exudate level and the depth of the wound):

Medisorb A – alginate dressing – heavy or moderate exuding wounds; superficial and deep wounds

Medisorb P - absorbent dressing – heavy or moderate exuding wounds; superficial wounds

Medisorb H – hydrocolloid dressing – moderate and low exuding wounds; superficial wounds

Red wounds

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Red wounds with visible granulation tissue required:

  • maintaining a moist environment
  • protecting against secondary infections
  • controlling the exudate level

Apart from maintaining a moist environment, these wounds also require protection against possible mechanical injuries. This is particularly important since a well-vascularised granulation tissue is susceptible to injuries which delay the healing process and can be the source of infection. Another important factor is to maintain the proper temperature (close to body temperature), so that new cells can grow at optimum speed.

Recommended dressings for red wounds (depending on the exudate level and the depth of the wound):

  • Medisorb A – alginate dressing – heavy or moderate exuding wounds; superficial and deep wounds
  • Medisorb P – absorbent dressing – heavy or moderate exuding wounds; superficial wounds
  • Medisorb H – hydrocolloid dressing – moderate and low exuding wounds; superficial wounds

Pink wounds

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Pink epithelising wounds require:

  • maintaining a moist environment
  • protecting sensitive tissues

When the wound begins to cover with epidermis it needs to be protected against drying out, friction and other factors that could damage the newly formed tissue.

Recommended dressings for pink wounds (depending on the exudate level and the depth of the wound):

  • Medisorb H – hydrocolloid dressing – moderate and low exuding wounds; superficial wounds
  • Medisorb F – film dressing – low exuding wounds

The analysis of wound healing phases shows that wounds being at various stages of healing, require some other conditions for the process to run smoothly. It is important to remember that in addition to various healing stages, the wounds are also varied because of the size, depth, presence of necrotic tissue and exudate level. All these features result in the fact that each wound requires the selection of the right kind of dressing, sometimes even a few dressings that will change during the healing process.

The following table presents factors that may slow down the healing process.

Table: Factors slowing down the wound healing process

slowing down factor why optimum conditions how does it work in optimum conditions
dry environment moist environment appropriate level of wound exudate: allows activation of natural wound debridement; accelerates granulation; provides quick and correct course of epithelisation
necrotic tissues wound healing is possible only after the removal of dead tissues; the necrosis may be a substrate for the development of infection curgical / autolytic wound cleansing cleansed the wound enable the begin of the granulation phase
infection all mechanisms in the wound tend to fight the intruder; the healing process is hampered fight infection cleansed the wound enable the begin of the wound healing process

Prevention

Basic rules:

  • systematic change of body position every two hours and reduce pressure in places at risk, through the use of special pressure relief mattresses and pads
  • adequate nutrition and hydration
  • protect the skin by the use of additional breathing aids – diapers, special protective dressings – polyurethane film dressing and appropriate skin care products
  • documentation of symptoms and changes in body position