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Bedsores and Personal Care Services

Last Updated: April 4, 2013

By Jeannette Franks, PhD

Family members with someone in long-term care need to be knowledgeable and vigilant about decubitus ulcers-the dreaded bedsores.

Bedsores, also called pressure sores, pressure ulcers, or decubitus ulcers, are skin wounds resulting from prolonged pressure on the skin in contact with a bed or wheelchair. Bedsores are painful, take a long time to heal, and are often a precursor of life-threatening complications such as skin and bone infections.

The human body is designed to be in constant movement, even while we sleep. We constantly shift positions, always unconsciously readjusting ourselves in bed, at the computer station, watching TV, or whatever active or inactive pursuit engages us.

How Bedsores Form

Bedsores form in the areas where we have the least padding of muscle and fat, especially right over a bone. Bedsores on the tailbone (coccyx), shoulder blades, hips, heals and elbows are the most common. Total immobility, even for as little as 12 hours, can cause bedsores.

Circulation is impeded when blood flow slows or stops in the compressed area between bone and the surface of a bed or wheelchair. When the tissue is deprived of oxygen and nutrients, the skin can die in as little as half a day, although the evidence may not be obvious for days or even weeks.

When surgery, injury to the spinal cord, or an illness causes immobility even for less than a day, the pressure of the immobilized body on certain areas can break down the skin. In bed, the most dangerous areas are the tailbone or buttocks and the heels. The toes, ankles, knees, hipbones, shoulders and shoulder blades, and even the rims of the ears are also at risk.

In a wheelchair, the locations at highest risk are again the tailbone and buttocks, as well as shoulder blades and the spine, and the backs of arms and legs where they touch the chair.

Bedsores often start at the hospital. Whether before or after surgery, many injuries make movement painful or impossible. It only takes a half a day, immobilized in bed, for a bedsore to start, especially if the person is already compromised by age, dementia, poor circulation, thin skin, incontinence, or nutritional deficits.

Problems such as arthritis or injury that make movement painful or impossible increase the probability of bedsores. Diabetics and paraplegics who have no sense of feeling in their feet are especially at risk.

Two Additional Causes of Bedsores: Friction and Shear

Shearoccurs when the skin moves in one direction and the underlying bone in another direction. Slowly sliding or slumping down in a bed or chair can cause the skin to stretch and tear. Transferring from bed to wheelchair or vice versa can also cause skin tears from shear.

Frictioncan also cause the skin to degrade. Even though frequent changes in position are important to prevent bed sores, the constant movement and rubbing can again break down skin. The gentlest assistance can still cause a skin wound, especially since human skin gets thinner and more fragile with age.

Good skin hydration with lotion can be helpful, and of course it is important to keep all skin clean and dry.

Risk factors

Age is the greatest of risk factors. That means the older the person, the more vulnerable is the skin. A gross insult to teenage skin, such as a huge abrasion and broken bones from skateboarding, may recover rapidly, even after a week in bed. But for an immobilized older person, a small skin tear, even from a gentle transfer from wheelchair to bed, might quickly develop into a bedsore.

Other risk factors include smoking, lack of pain perception, urinary or fecal incontinence, malnutrition, dementia, and other medical conditions such as diabetes.

The Four Stages of Bed Sores

The earliest stage,Stage I, is a persistent area of red skin that may itch or hurt. The spot can feel warm or spongy to the touch; conversely it may feel hard. In darker skin, the patch may look blue or purple, or appear flakey or ashen. Stage I wounds will usually disappear promptly if the pressure is relieved.

Stage IIbedsores indicate that the skin is already compromised. An open sore that looks like a blister or abrasion is a red flag. The surrounding area may be discolored. When treated promptly, these sores can heal quickly if the person is otherwise in good health and not experiencing other problems such as diabetes or paralysis.

Stage IIIbedsores indicate that the pressure ulcer has extended through all the skin layers down to muscle. The deep, crater-like wound indicates permanently destroyed tissue. Stage III bedsores are often extremely painful and difficult to treat.

Stage IVbedsores, the most serious and advanced stage, destroy muscle, bone, and even tendons and joints. Stage IV bedsores are often lethal.

Prevention

Positioning
Repositioning the body at least every two hours in bed, or every 30 minutes in a wheelchair, can help prevent bedsores, as can special beds, pillows, and mattresses. However, this repositioning can cause its own problems. It is miserable to be awakened every two hours, especially if you are recovering from illness, surgery, or an accident. Moving anyone every two hours, or especially every 30 minutes, is an enormous staff challenge for any facility providing personal care services, particularly in a busy hospital or nursing home. And people with dementia and/or pain will suffer and quite reasonably protest.

Proper position can minimize the risk of bedsores. Avoid lying directly on the hipbones and support legs correctly with a foam pad or pillow (never a doughnut-shaped cushion or any type of rubber pad). Put the support under the legs from the middle of the calf to the ankle and keep knees and ankles from touching. It's helpful to have a little tent over the toes, and to use special heel pads.

Avoid raising the head more than 30 degrees and use pillows or foam wedges to help the person to sit up to eat. Expert advice and assistance is crucial. Do not try to reposition a frail person alone.

Specially designed mattresses and beds are available. Different options of foam, air, gel, or water in a bed that can be automatically or manually readjusted on a regular schedule can work well. Again, consult an expert, especially if a person is paralyzed or has other risk factors such as dementia, age over 75, poor nutrition, or poor circulation.

Inspection
Inspection isthe crucial component of care and prevention and can also catch problems in the early stages, when they are much easier to cure. Unfortunately, inspection can also be undignified at best and humiliating at worst. I remember an enormous uproar because a state memo went out ordering social workers to examine nursing home residents for bedsores. There is no decent way to ask someone to let you look at his or her backside, especially if you are not a doctor or nurse. After a flurry of testimony and anguished letters, the order was withdrawn.

Well-trained nurses' aides are the most important front-line defense. These hard working women and men do the bathing and toileting, change bedding and clothing, and perform the most intimate personal care services. If they are well educated and alert to the possibility of bedsores, they are the best defense. While the family can be helpful in repositioning, supporting the hands-on caregivers, and keeping an eye on good care, they rarely see the family member nude. I don't know about you, but I never saw my father naked, and hope I never will.

Treatment

Often the situation that precipitates a bedsore makes it very challenging to treat. Conditions such as diabetes, thin skin, and immobility make healing difficult. As noted, Stage I bedsores will usually disappear if repositioning is prompt and consistent. A physician's written orders can help this happen.

Stage II, when a wound is present, calls for a multi-disciplinary approach coordinating the physician, the nurses, the aides, and perhaps a physical therapist. Sometimes a social worker can help manage the personal care services provided. A careful analysis of how the wound was precipitated will help determine treatment. A change of bed, cushioning, skin care, and/or clothing may be effective. Support surfaces are particularly important and special padding such as sheepskin or waffle foam can help. Low-air-loss beds use inflatable pillows for support; air-fluidized beds suspend the patient on an air-permeable mattress that contains millions of silicon-coated beads.

Improved nutritioncan aid healing. Dark red, orange, and green vegetables are especially rich in the needed nutrients, and nutritional supplements of Vitamin C and zinc can also be helpful.

Cleaningis crucial. Open sores may be treated with a saline (saltwater) solution each time the dressing is changed. Be sure that the issue of pain is well addressed. "Rubbing salt into the wound" may be a cliché, but it's also the description of torturous pain. Continence issues are important-perhaps a catheter might be used until the wound is healed. Medication modification, incontinence pads, and more frequent toileting also might be helpful and less invasive.

Debridementis the removal of damaged tissue. Surgical debridement is often recommended to remove dead, damaged, or infected tissue. Nonsurgical treatments include irrigation with pressurized water, hydrotherapy in a whirlpool bath, using the body's own enzymes, or applying topical debriding enzymes.

Dressingshelp speed healing and protect the wound. It is crucial to keep surrounding skin dry and the wound moist. Transparent, semi-permeable dressings can help retain moisture and encourage new skin to grow. Infected wounds may be treated with topical antibiotics. Again, it is crucial to also treat the pain in this difficult process.

Even with the best medical care, bedsores may requiresurgery. Healthy tissue may be taken from one part of the body to use in reconstructing the damaged area. Recovery is long and arduous with frequent complications. Prevention is still the best treatment. 

 

Bedsores and nursing homes

The highest percentage of people with bedsores are in nursing homes. Some bedsores may have been acquired in the hospital, and then persisted when the person transferred to a skilled care facility. The prevalence varies from study to study, and facility to facility, but anywhere from 3 to 28 percent of the people in a nursing home may have bedsores.

It's a chicken and egg situation: which came first, the bedsore or the environment? Often frail older people come to live in a nursing home because this injury is so difficult to prevent and treat at home. Sometimes the conditions that necessitate living in a nursing home, such as advanced dementia or paralysis, create the bedsore.

Federal regulations are particularly stringent about preventing, documenting, and treating bedsores. The website www.medicare.gov (click on "Compare Nursing Homes in Your Area") gives the ratings for every nursing home and tells you the percentage of residents with bedsores and how that compares with the national average.

While this is useful information, a few caveats are in order. One nursing home may specialize in some personal care services such as wound care, and thus have a much higher number of cases of bedsores than another facility. Some facilities specialize in dementia care, where most residents are mobile, and thus have a low number of people with bedsores. So the percentage of residents with bedsores may not necessarily be a measure of quality of life. 

 

Jeannette Franks, PhD, is a passionate gerontologist who teaches at University of Washington and Bastyr University; she is the author of a book on assisted living and numerous articles.

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