Bedsores, often referred to as pressure ulcers and pressure sores are skin and tissue injuries that occur as a result of pressure in combination with friction and/or shear. The usual sites of bed sores are on sites where the skin overlays the sacrum, coccyx, also known as the tailbone, on the hips, and heels, as well as knees, elbows, ankles, back of the shoulders and the back of the cranium. These pressure ulcers happen because of the pressure applied to the soft tissue that subsequently obstructs the blood flow to the soft tissue.
Most commonly, bed sores develop on the individuals who are immobile or moving very little, such as bedridden patients, as well as those confined to a wheelchair. However, there are other factors that can contribute to the occurrence of bed sores, such as some diseases that significantly reduce the blood flow to the skin, for example, arteriosclerosis, paralysis, and neuropathy, as well as protein malnutrition, the microclimate of the skin.
Pressure ulcers can occur and develop quite quickly and can be very difficult to treat, however, some factors and precautions can be taken to speed up and help with the healing process. A contributing factor in the treatment of bed sores can be the age of the patient and his medical condition, such as diabetes or infection, as well as the patient’s lifestyle habits such as smoking or taking anti-inflammatory medication.
One of the primary precautions one can take is to regularly move the bedridden or wheelchair confined person. This is beneficial for the prevention of future sores. Additionally, a proper balanced diet with enough of protein and keeping the skin clean and free from urine and other bodily secretions is of utmost importance.
Stages of pressure ulcers
There are four defined stages of pressure ulcers which are being periodically revised by the National Pressure Ulcer Advisor Panel in the US and in Europe, by the European Pressure Ulcer Advisor Panel.
In this stage, one can see red skin that does not blanch (lighten briefly) on the area which is usually located over a bone prominence. The area might differ in thickness or temperature from the surrounding tissue and may become tender and painful. On the individuals with darker skin, the area may show some discoloration and would not blanch upon touching.
In the second stage, one loses the epidermis (the outer layer of the skin) and dermis (underlying layer of the skin). A shallow open ulcer develops with a pink or red wound bed. At this point, the affected area may have an appearance of a fluid-filled or a ruptured blister.
At the third stage, the ulcer becomes a deep wound, which means the full thickness tissue loss. Some fat can be exposed at this stage, but bone, muscles, and tendons are still not visible. There could be some slouch, but it does not obscure the depth of the tissue loss. The ulcer looks like a crater and the damage may expand beyond the wound and below the layers of skin.
At this stage, ulcers show a substantial loss of tissue. This means that bone, tendon, and muscle are exposed. There could be some slough or eschar (dead tissue) present on some parts of the wound. Stage four ulcers can extend into the supporting structures of the body when the inflammation of the bone and bone marrow is likely to occur.
Pressure ulcers are considered unstageable if their surfaces are covered with dead tissue, or yellow, brown, gray, or black slough, thus making the assessment of the depth of the wound virtually impossible.
Deep tissue injury: In this case, the skin is purple or maroon but not broken and there is a blood-filled blister located on the area which is painful and firm, and/or mushy. The affected site differs in temperature to the surrounding skin, and the wound may develop and be covered by eschar. The development of such wounds can be very rapid even with proper treatment.
How to treat bed sores?
Stage one and two bedsores can usually be healed in a few weeks or months, but pressure ulcers in the third and fourth stage can be much more difficult to heal. The first thing one should do is to reduce the pressure that caused bedsore. That can be done by repositioning the patient regularly and placing him or her in a proper position. Wheelchair-confined individuals should shift their weight every ten to fifteen minutes. Caregivers should be wary of friction and shearing when repositioning the patient. Another way of repositioning is through the use of support surfaces such as mattresses, beds, and cushions which can help relieve the pressure on bed sores.
Patients should be repositioned every two hours, and bedbound patients should be placed at a 30° angle when lying on the side. They should avoid sliding over the bed surface to avoid friction. Patients at high risk of ulcer development should be put on pressure-reducing devices such as foam, gel, or water devices.
Cleaning and properly dressing these wounds is of utmost importance. One should clean the wound properly to avoid the risk of infection. For stage one bedsores, simply use mild soap and water, and for open sores use saline solution upon each dressing change. Dressings are used to keep the wound moist and to help with the prevention of infections. Gauzes, films, foams, and gels can be used for pressure ulcers; however, a doctor should choose the one most appropriate for the individual wound.
Dressings that are most commonly used for bed sores include alginate sheets and fillers which have absorbing qualities and promote autolytic debridement; foams that obliterate dead space, retain moisture, and help with mechanical debridement; woven and nonwoven gauzes; hydrocolloids that provide occlusion and obliteration of dead space, as well as moisture retention; hydrogels that retain moisture; transparent films that provide occlusion and help with debridement; wound fillers and wound pouches that help with the control of exudate.
In order to heal properly, bedsores must be debrided of infected or dead tissue. This can be done in a number of ways, such as surgical debridement which basically means cutting the dead tissue out, mechanical debridement which removes the debris with the help of a pressurized irrigation device or special dressings, enzymatic debridement – applying chemical enzymes which break down the dead tissue, and autolytic debridement which helps the body use its natural enzymes to break down the dead tissue and can be used on smaller wounds.
Bed sores can be quite painful; therefore, proper pain management is of the essence. Some medications such as ibuprofen and naproxen may be useful in pain reduction, before or after debridement, repositioning, and dressing changes, and one can also use topical pain medications to alleviate the pain. Antibiotics can also be used to treat infected bed sores unresponsive to other interventions.
Keeping a healthy diet is essential for the healing of a pressure ulcer. A dietitian could recommend a diet change or adjustment, as well as fluid increase, or a high-protein diet. A patient should eat foods rich in vitamins and minerals and possibly take supplements of vitamin C and zinc. Additionally, for patients with incontinence issues, helping with urination and diaper changes can help speed up the healing process and keep the wounds clean. A doctor may also prescribe muscle relaxants such as tizanidine, dantrolene, or diazepam to help with muscle spasms that can cause friction and shearing. Finally, negative pressure wound therapy can also be used to alleviate the pain and help with debridement and healing of pressure ulcers.
Some pressure ulcers that do not respond to these methods of healing may require surgery. Surgeries can help with the hygiene and infection treatment of the wound, reduction of fluid loss, and finally, lowering the risk of cancer of these sores. The type of the surgery depends on the state and location of the wound, but generally, most bed sores are fixed by using a pad of skin, muscle, or other tissue to cover the sore and protect the bone.
Hydrogen or iodine cleansers should not be used on bed sores as they can damage the skin and slow down the healing process. Additionally, povidone-iodine can affect the function of the thyroid gland, so it could cause contraindications in some patients. Also, one should definitely consider losing excess weight and getting enough sleep, and avoid massaging the surrounding skin as this can cause even more damage. Wheelchair-confined patients should avoid using donut shaped cushions as they reduce the blood flow which can also be a cause of sores.
If you detect a foul odor coming from the ulcer or if you see pus coming out of it, call your doctor immediately. Also, if the surrounding skin is sore to the touch and warmer or colder than the surrounding area, as well as swollen, professional assistance is needed. Finally, if you have a high fever, call your healthcare provider.
Other treatments with unproven efficacy that may help include hyperbaric oxygen therapy, growth factors, and electrotherapy, however, there is scarce evidence that these actually have benefits for the patients.
There are a few household items that can help with healing of bed sores. Simple saline water can definitely help bedsores heal faster, as well as clean them thoroughly. It will also reduce excess fluids and possibly help with getting rid of the loose dead skin.
Turmeric is another home remedy that has anti-inflammatory, antiseptic, and antioxidant qualities that can help the body heal. After cleaning the wound with sterile water or saline, sprinkle some turmeric powder over the wound and cover with a clean dressing. Additionally, one can drink warm turmeric milk twice a day to help the healing process.
Honey and aloe vera are also quite popular home treatments. A thick mixture of honey and sugar can be applied to the affected area and bandaged properly. Aloe vera gel can be applied to the wound three times a day to moisturize the skin and soothe the pain.
Gently massaging the legs, back, and limbs, avoiding the sore area with coconut oil can help the patient relax his muscles and moisturize the skin. In addition, taking enough vitamin C either through supplements or vitamin C-rich foods such as lemons, oranges, bell peppers, and grapefruit can help with the healing due to their anti-inflammatory properties.
Limiting the exposure to dry air and cold weather can help as well, avoiding tight and heavy clothing, and dressing in clothing made of natural materials can aid in avoiding possible pressure sores. Finally, drinking enough water keeps the skin hydrated and elastic, thus helping with the prevention of bedsores.