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POPPE: Library/Elder Abuse/Identifying Bedsores
Have a loved one who is bedridden? Whether at home or in a nursing facility, it is
imperative this person regularly change positions. In cases where a patient can’t help him
or herself, “turning” insures pressure against the body is relieved, even for a short time. If
possible, the person should sit up, stand or walk with assistance to avoid lying in one
position in bed.
Lying in the one position fosters pressure by way of friction with the mattress, wrinkled
clothing or a tangled bed sheet. The heels of the foot, shoulder blades, tailbone and
elbows are points where friction against the underside of the body is acute. Bedsores are
caused by 1) pressure such as the compression from the force of bone against surface; 2)
shear force when skin tissue or muscle sags with gravity or when the skin moves in one
direction and the underlying bone in another, pinching a blood vessel, restricting blood
flow and depriving a skin area of healing agents oxygen and nutrients or 3) friction,
which may cause shedding of epidermis layers. Incontinence and perspiration contribute
to bedsores as moisture breaks down bonds between cellular tissues which can break
down the epidermis.
With prolonged, unrelieved pressure, sores develop. Commonly called bedsores, they are
termed pressure ulcers or decubitus by doctors. These sores are defined and revised by
the National Pressure Ulcer Advisory Panel, a professional organization dedicated to the
prevention and treatment of pressure sores.
Stage One is referred to as superficial, where redness may occur and pain may be felt to
the touch, although there is no skin tissue damage. Stage Two involves open wounds and
damage to the epidermis and into but no deeper than the dermis. The sore is referred to as
an abrasion or blister. Stage Three features a crater-like wound into but not through the
subcutaneous skin layer. This layer has limited blood supply or circulation, so it becomes
difficult to heal. With this stage, there may be more damage than apparent. Stage Four is
the deepest wound, which extends into the muscle, tendon, joint or bone. Dead skin cells
and wound fluid can mask the wound’s depth. According to the MayoClinic.com, Stage
Four pressure sores are “extremely difficult to heal and can lead to lethal injections.”
There are two theories about pressure ulcer formation. The most accepted is the deep
tissue injury theory, claiming ulcers begin deep near the bone and destroy tissue as they
move outward toward the epidermis. The second theory contends skin deteriorates at the
outer surface and moves deeper into the body.
As with any open wound, controlling infection is at issue. Discharge of pus (bacterial,
yellowish-white liquid) is a breeding ground for excess bacteria, especially in patients
with weakened immune systems. Symptoms include fever, pain, skin redness, skin
warmth and odor. Antiseptics are recommended but hydrogen peroxide is not. Bandage
dressings should be changed frequently
For patients with Stages One and Two ulcers, the wound care team should use guidelines
established by the American Medical Directors Association (AMDA) for treatment of
these lower-grade sores.
For those with Stage Three or Stage Four sores, surgery such as a tissue flap, skin graft or
other closure methods may be necessary to counter anemia, gangrene or sepsis. Gas
gangrene can produce toxins that completely destroy muscle tissue. Sepsis occurs after
bacteria from a massive infection (Stage Four) enters the blood and spreads rapidly,
possibly causing shock as well as organ failure.
A more recent intervention is negative pressure wound therapy, which is the application
of topical negative pressure to the wound. This technique, developed by scientists at
Wake Forest University, uses foam placed into the wound cavity which is then covered in
a film which creates an airtight seal. Once this seal is established, the technician is able to
remove pus and other infectious materials in addition to aiding the body to produce tissue
for the creation of new skin layers.
In the most severe case (someone with paralysis) pain from the development of a pressure
sore cannot be sensed. With no warning signals, the patient doesn’t know to shift their
position in bed. For smokers, their ability to physically fight a pressure sore is
compromised since nicotine impairs blood flow and reduces oxygen in the bloodstream.
Older individuals tend to have thinner skin and are susceptible to physical injury from
pressure, friction or shear on the body. They weigh less, meaning there is less muscle or
fatty tissue surrounding bones. If someone has poor nutrition, their skin and blood vessels
are weakened, making them vulnerable to wound formation. The healing and re-growth
rate of skin cells declines in an elderly person who may be fighting a pressure sore.