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Cheryl Boldt, RN

Bedsores, also called pressure ulcers, have become a common as well as serious health problem for patients in hospitals and nursing homes. In fact, each year about one million people in the United States develop bedsores ranging from mild inflammation to deep wounds that involve muscle and bone. The Federal Agency for Health Care Policy and Research has reported that bedsores afflict:

    * 10% of hospital patients
    * 25% of nursing home residents
    * 60% of quadriplegics

Bedsores can be slow to heal, and without proper treatment, they can lead to severe medical complications, including bone and blood infections, infectious arthritis, and scar carcinoma. These complications slow the healing process, increase the cost of treatment, lengthen hospital or nursing home stays, and can even cause death. In fact, approximately 60,000 deaths a year are attributed to complications caused by bedsores.

The Cause
Bedsores generally form at points of pressure, where the weight of the patient's body presses the skin against the firm surface of the bed. In people confined to a bed, bedsores are most common over the hip, spine, lower back, shoulder blades, elbows, and heels. In people who use a wheelchair, bedsores are most common on the lower back, buttocks, and legs. This pressure temporarily cuts off the skin's blood supply, which injures skin cells and causes them to die.

Unless the pressure is relieved and blood is allowed to flow to the skin again, the skin soon begins to show signs of injury. At first, there may be only a patch of redness. However, if this red patch is not protected from additional pressure, the redness can rapidly form blisters or open sores (ulcers). In severe cases, damage may extend through the entire thickness of the skin and create a deep crater that exposes muscle or bone.

While constant pressure on the skin is the most common cause of bedsores, other factors can contribute to the problem. These include, but are not limited to:           
The Four Stages of Pressure Ulcers

Pressure sores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:

Stage I. Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. Stage I wounds are superficial and go away shortly after the pressure is relieved.

Stage II. At this point, some skin loss has already occurred. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

Stage III. By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.

Stage IV. In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.

Shearing forces and friction. Shearing and friction causes skin to stretch and blood vessels to kink, which can impair blood circulation in the skin. In a person confined to bed, shearing and friction can occur when the person is dragged or slid across the bed sheets.

Moisture. Wetness from perspiration, urine or feces can make the skin extremely soft and more likely to be injured by pressure.

Decreased sensation. Bedsores are common in people who have spinal cord injuries or other neurological problems. Without the ability to feel pain or discomfort, the person cannot feel the effects of prolonged pressure on the skin and therefore doesn't ask for assistance in shifting pressure away from the affected area.

Poor nutrition. If a person is poorly nourished, he or she is more likely to develop bedsores. Studies show that bedsores are more likely to develop in people who have an inadequate daily intake of protein, vitamin C, vitamin E, calcium or zinc.

Age. Elderly people, especially those over 85, are more likely to develop bedsores because skin usually becomes thinner with age.

Prevention Measures
It's possible to prevent bedsores from developing or worsening. In fact, experts believe that simple measures to relieve pressure can prevent at least 50 percent of bedsores. To help prevent bedsores in a person who is confined to a bed or chair, you should do a comprehensive evaluation and create a plan of care. The plan should include these strategies:

Inspect the person's skin daily. Early detection can prevent redness from becoming worse. Pay special attention to vulnerable areas such as the hip, spine, lower back, shoulder blades, elbows, heels, and legs.

Change positions. If confined to a bed, change the person's position every two hours. A person who uses a wheelchair should shift his/her weight every 10 or 15 minutes, or be helped to reposition at least once an hour. It's important to lift, rather than drag a person who is being repositioned.

Get the right support. Use pillows and foam wedges as needed to raise the person's arms, legs, buttocks and hips. Relieve pressure on the back with a therapeutic pressure reducing gel, foam or water mattress or overlay. Donut-shaped cushions should not be used because they restrict blood flow and cause tissues to swell.

Be cautious of irritating chemicals. Avoid using irritating antiseptics, hydrogen peroxide, iodine solutions or other harsh chemicals to clean or disinfect the skin.

Encourage daily exercise. Exercise increases blood flow and speeds healing. In many cases, even bedridden people can do stretches and isometric exercises.

Keep the skin clean and dry . Clean the skin with saline rather than harsh soaps. Use absorbent pads to draw moisture away from vulnerable areas. Sheepskin padding also reduces moisture on the skin. The fibers can hold between 30 and 36 percent of the sheepskin's weight in moisture, without feeling damp. With moisture drawn away from the skin and into the fibers, another cause of bed ulcers/bed sores can be eliminated.

Use hydrotherapy. Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue.

Promote a healthy diet. A nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals - especially vitamin C and zinc - has been shown to improve wound healing.

If these measures don't help with prevention and treatment, antibiotics may be prescribed, which may be applied as an ointment, taken as a pill or given intravenously. If necessary, larger areas of dead tissue may be trimmed away surgically or dissolved with a special medication. Remember that immediate medical attention is required whenever:

    * Skin turns black or becomes inflamed, tender, swollen, or warm to the touch.
    * The patient develops a fever during treatment.
    * The sore contains pus or has a foul-smelling discharge.

As healthcare professionals, we have the ability and resources to prevent and effectively treat this condition before it becomes life threatening. So take note and take this information to heart!

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