Pressure Sore Treatment in Bed bound and Compromised Patients

Pressure sores or Bed sores are the sum total of several factors at work in a bed bound patient or a patient which tends to spend a greater amount of time immobile than mobile. These factors are constant pressure or consistent pressure, poor nutrition, poor circulation and poor hygiene resulting in a skin infection or ulcer. In the United States an ulcer of this type is rated in Stages. Stage 1 is a reddening of the area, Stage 2 is redness with a blistering of the area, Stage 3 is a breakdown of the uppermost layers of skin or the dermis, Stage 4 is a breakdown of the subcutaneous skin layers including deeper tissue and even muscle fascia. Once an ulcer or pressure sore has started, the sore is extremely hard to reverse without extraordinary means such as specialized care. Specialized care can include, load reducing surfaces such as air beds, special dressings such as permeable (breathable membrane) dressings, and even in the event of some Stage 4 ulcers packing and irrigation with fluids on a daily basis or more. It is because of a patients pain and discomfort and the cost of specialized care that pressure ulcers should be prevented at all costs. Management of bedsores can cost tens of dollars a day in the event of specialized dressings to hundreds a day for a combination of dressings, load reducing surfaces and special wound care attention. Therefore prevention of the four major causes of pressure ulcers is the best way to manage a compromised patient.

1. Constant pressure or consistent pressure on any one area is especially hard to avoid. Patients will have a favorite or dominant sleeping or resting position and, if the patient has a partial paralysis or painful side they may favor or stay away from that side. Guiding the patient to stay off a side must be done comfortably but firmly in order to rotate their positions on an average of two to four hours at a time to give the opposite sides time to heal or be nutrified by the circulatory system. While resting on their side the patient should be positioned at a fifteen to thirty degree angle and not a ninety degree angle in order to keep the patient off the trochanter or hipbone. When lying supine or on their back the patient should have at least a ten degree incline to their back or torso and have a ten degree lift to their hips. Shearing injuries are injuries caused by pressure applied to the skin in movement while the skin is loaded down or pressurized by the patient’s weight. The patient being moved in this manner stretches the skin beyond a normal amount that it can resist, tearing the tissue either obviously, in the event of a skin tear which may be bloody and may separate the skin area or not obviously that may result in a reddening of the area. These injuries can be caused by a patient slouching or slipping in bed as a result of the degree of incline of their back being too great, or by a caregiver moving the patient without lifting their weight off the bed surface before the movement. The most common bedsore which appears at the coccyx or tailbone is normally a result of this type of injury.

2. Proper nutrition will help to prevent breakdown by keeping the tissues pliant resisting shearing. Nutrition is also responsible for giving the body the means to repair shearing injuries quickly and prevent infection. A balanced diet for a compromised patient can be maintained by watching the food choices offered and giving the patient palatable or tasty choices to keep them motivated to eat.

3. Good circulation will nutrify the tissues by benefit of the circulatory transport system. The lack of circulation will speed up the infectious process and decrease the patient’s ability to repair tears or heal infections. When a position is held for too long the blood pools decreasing circulation. This condition is called circulatory stasis. Blood caught in this condition does not renew its nutrients and will not be able to deliver nutrients to the tissues. The process of pooling will always happen at the surface which touches the bed and will starve that area of nutrients when it may be needed to resist shearing or infection.

4. Hygiene is the last consideration because after the previous conditions have been put in place the doors have been opened for infection. Shearing injuries, combined with the bodies’ inability to repair them breaks the initial defenses of the skin. Necrosis or tissue breakdown is promoted by the presence of bacteria often of the common skin variety such as staph and ecoli. Staph is present on most skin surfaces and ecoli is present when stool has been mismanaged during care. These and other infections, some present in the hospital environment, will promote the ulcerative conditions and cause the patient to be treated by extraordinary means such as antibiotics, specialized dressings and special bed surfaces.

All of these conditions can be prevented by non-extraordinary means such as proper positioning, good nutritional practices and good hygiene. Positioning remains the only effort that needs to be maintained by any extra equipment. Maintaining a patient with normal bed surfaces can be done with a minimum investment in positioning tools for this purpose. Click here for a list of positioners which use standard pillows and washable pillow forms which can be purchased for this purpose.

References: Clinical Practice Guidelines, #15; “ Treatment of Pressure Ulcers,” U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, December, 94, Journal of Wound Care and Continence Nursing, Vol.29, #3; “ The Effect of 10 degree Leg Elevation and 30 degree Head Elevation on Body Displacement and Sacral Interface Pressures Over a 2hour Period,” Chizuru Harada, Toyomi Shigematsu, and Satsue Hagitsawa, May 2002