Pressure Ulcers In Bedridden Patients - Risk And Stages Of Pressure Ulcer Development, Skin Treatment. How To Treat Bedsores?

2024 Author: Josephine Shorter | [email protected]. Last modified: 2024-01-15 09:49

The risk and stages of pressure ulcers development, how to treat?

Content:

• What are bedsores?
• The first signs of bedsores
• Why are bedsores dangerous?
• Pressure ulcer risk factors
• Stages and degrees of pressure ulcers
• Purulent bedsores
• Treatment of the skin for bedsores
• Bedsores on the heels and buttocks
• How to treat bedsores?

The development of pressure ulcers on the body complicates the treatment of patients in intensive care wards, geriatric wards, as well as during the rehabilitation period at home, after heart attacks, strokes, with spinal paralysis, complex limb fractures, spinal injuries, coma, other pathologies, with the forced finding of a person in a monotonous pose.

What are bedsores?

Bedsores are a pathological change in the skin, subcutaneous tissue, muscles, bones, and other tissues of the body, developing as a neurotrophic disorder, the causes of which are a violation of the innervation, blood and lymph circulation of a local part of the body, with prolonged contact with a hard surface.

Brief description of pathological changes on the body:

• develop on the side of the body adjacent to a hard surface;
• characterized by staged pathogenesis, begin with stagnation of blood circulation, in the absence of treatment, end with neurotrophic necrosis of wet or dry type, sepsis or gas gangrene;
• most rapidly, during the day, develop in emaciated patients, with congestion in cardiovascular insufficiency;
• localized on protruding parts of the body, the most typical lesions are:
• when the patient is on his back, the region is affected (sacrum and coccyx, buttocks, spinous processes of the spine, the area of the shoulder blades, heels);
• when the patient is on his stomach, the area is affected (knee joints, iliac crests, protruding surface of the chest);
• when the patient is on his side or half-sitting, the area (ischial tubercles) is affected;
• rarely localized on the back of the head and folds of the mammary glands.

Specific localization of pressure ulcers on the skin: under plaster casts, in places of tight fit of materials that do not penetrate moisture (oilcloth diapers, rubber tubes), folds of bedding, bandages, etc.

Specific localization of pressure ulcers on the mucous membranes: under dentures, with prolonged drainage of the urethra - on the urethra, with prolonged catheterization of blood vessels - on the vascular mucosa.

Pressure ulcers rarely develop in people at a young age who are conscious, without a history of chronic illness. Usually in this category of patients, if bedsores are present, they develop gradually, there is a high probability of missing an impending pathology.

The first signs of bedsores

• Subjective sensations that the patient can communicate to caregivers, while being conscious and preserved pain sensitivity of body parts:
• tingling on the skin in places where pressure sores are likely to develop, associated with stagnation of biological fluids (blood, lymph) feeding the nerve endings;
• loss of sensitivity (numbness), after about 2-3 hours in this area of the body.
• Visible signs of an incipient pressure ulcer that caregivers must know:

• stagnation of peripheral blood and lymph, at first in the form of venous erythema of a bluish-red color, without clear boundaries, with localization at the point of contact of the bone, muscle protrusions of the body with the bed of the bed, the intensity of skin staining: from barely noticeable to saturated;
• sloughing of the epidermis of the skin with or without the preliminary formation of purulent vesicles.

These are signs of an incipient bedsore. It is urgent to take measures to prevent further aggravation of the pathology.

What to do to eliminate the first symptoms of a pressure ulcer?

This requires:

• change the patient's posture every two hours, if there are no contraindications, it is recommended to use special pillows to change the position of the limbs and body relative to the bed surface, forming gaps between the skin and the bed;
• monitor the level of the head of the patient's bed, the head should be lower or level with it;
• regulate the moisture content of the patient's skin with hygiene products (washing cream, foam, solution, spray, warm baths can be used (it is forbidden to use hot water), do these procedures from twice a day, with uncontrolled defecation, remove contamination as quickly as possible;
• remove excess moisture from the skin and skin folds (water, liquid food residues, urine, wound exudate, sweat) using special absorbent pads, diapers, napkins, towels, films;
• regularly remodel the bed or change the bedding at least once a day;
• do not do an intensive massage, light stroking of areas of skin with signs of stagnation is allowed, carry out this procedure carefully, without friction, especially in areas with a close location of bones;
• use anti-decubitus mattresses of the balloon or cellular type, equipped with special silent compressors to maintain and change the rigidity of its base, with adjustable and programmable inflation of different areas.

• use, for patients in wheelchairs, pillows filled with gel, foam, air, monitor the change in body position in the chair at least once an hour.

Why are bedsores dangerous?

Pressure ulcers belong to pathologies, the treatment of which is better to avoid. If this could not be done, then with the formation of foci of maceration of the skin, pathogenesis develops very quickly, with the formation of foci of tissue necrosis and is characterized by long-term treatment of a purulent wound. The outcomes of bedsores are dangerous. In some cases, bedsores are the cause:

• extensive excisions of soft tissues and the formation of defects with impaired innervation and blood circulation of the underlying parts of the body,
• lower limb amputations;
• necrotic lesions of the periosteum and bone tissue in the form of osteomyelitis, periostitis;
• depletion of the body's defenses, complicating the treatment of the underlying disease;

With the development of pressure ulcers by the type of wet necrosis, wound infection occurs, with the development of purulent processes (phlegmon, sepsis, gas gangrene).

With the development of pressure ulcers of the type of dry necrosis, a protracted pathogenesis develops with long periods of defect healing.

Causes of bedsores

The cause of bedsores is as follows. Our body is completely riddled with small blood vessels. Through these vessels - capillaries - blood flows to various organs of the body. If the blood vessels are squeezed, then the blood ceases to flow to the tissues, as a result of which the tissues die.

If a person is stationary for two hours, his blood vessels are compressed and blood stops flowing to certain areas of body tissues. Therefore, bedsores are formed. Remember that it is very dangerous to sit or lie still for a long time.

Also, bedsores are formed if a wet sheet is often pulled out from under a sick person. In this case, blood vessels rupture. This is completely invisible to the human eye. But after the rupture of the blood vessels, blood ceases to flow to the tissues. Bedsores form.

Also, blood vessels can rupture if a person cannot, for example, walk and constantly slides down to take a different position.

Risk factors for pressure ulcers

It has been noticed that bedsores develop in bedridden patients at different times. In medical institutions, to systematize the assessment of risk factors for the development of pressure ulcers, the Norton, Braden or Waterlow scales are used. At home, they don't matter. On the basis of these criteria, the risk factors associated with errors of care and the individual characteristics of the patient, suitable for home use, are formulated.

1. Factors associated with errors in the organization of patient care:

• untidy bed, changed less than once a day;
• rare change of underwear for dry and clean;
• neglect of hygiene procedures (treatment of the body with special solutions, drying, massage of body parts where possible without additional trauma to the bedsore);
• hard, uneven surface of the bed.

2. Factors associated with the individual characteristics of the patient's condition:

• elderly age;
• exhaustion or vice versa obesity of the patient;
• diseases of the cardiovascular system;
• diseases associated with a violation of the innervation of the body (including strokes);
• disorders associated with changes in metabolic processes in the body (diabetes mellitus, impaired water-salt metabolism, or the usual restriction in drinking);
• unbalanced nutrition or lack of protein food in the diet, protein dystrophies (protein metabolism disorders);
• the patient's condition (coma, dementia, other) in which he does not control bowel movements, urination.

In addition, factors that provoke the occurrence of pressure sores include smoking, diabetes mellitus, lack of water and little nutrition, excess or, on the contrary, very low weight, urinary and fecal incontinence, dirty skin, crumbs and small objects in bed, an allergic reaction to drugs skin care, folds, seams, buttons on underwear, as well as injuries and diseases of the spinal cord and brain, sweating at elevated temperatures.

Stages and degrees of pressure ulcers

The pathogenesis of pressure ulcers is characterized by stages of development. There are four stages of pathogenesis.

Stage I pressure sores

It is visually determined by venous erythema at the site where the skin adheres to a foreign surface. Venous erythema is the result of a difficult outflow of blood from a local area.

How to distinguish erythema venous from arterial hyperemia and bruising?

• Difference from arterial hyperemia:
• the color of venous erythema is red-cyanotic, the color of arterial erythema is bright red;
• the local temperature of venous erythema corresponds to the skin temperature or slightly lower, the local temperature of arterial hyperemia is a warm area of the skin at the place where the temperature is determined.
• Difference from bruise:
• red-cyanotic skin color at the point of finger pressure does not change (bruise)
• a similar skin color at the place of pressure turns pale (venous hyperemia).

Venous hyperemia (erythema) of the protruding bony parts of the human body adjacent to extraneous surfaces, without violating the integrity of the skin, is the most important sign of a pressure ulcer of the first stage.

Stage II bedsores

It is visually determined by the thinning of the epidermis - the upper layer of the skin, followed by peeling, the formation of bubbles. The pathogenesis develops as follows: venous stasis provokes a violation of tissue nutrition, innervation of a body area, excess fluid in the skin, causes swelling (maceration) and rupture of epidermal cells.

Superficial skin damage in the form of thinning and peeling of the epidermis, violation of integrity, maceration (moisture) is the most important sign of the second stage of a pressure ulcer.

Stage III bedsores

Visually defined as a wound with suppuration (seeding with microflora) or without suppuration.

Involvement in the pathogenesis of deep layers of skin tissues, subcutaneous tissue, muscles with a purulent type of inflammation and incipient processes of necrosis (tissue death) is the most important sign of the third stage of pressure ulcer.

Stage IV bedsores

Visually defined as a local cavity or defect formed as a result of decay (necrosis), along the edges of the cavity is filled with the walls of the defect on which purulent inflammation continues.

A necrotic cavity and its expansion due to inflammation of the walls is the most important sign of the fourth stage of a pressure ulcer.

On different parts of the body, there may be different stages of pressure ulcers.

Purulent bedsores

The suppuration of the decubitus site begins from the second stage, develops in the third and fourth, after seeding the wound with staphylococci, streptococci, and other pyogenic microorganisms of the site.

A common way of developing a purulent pressure ulcer is erysipelas and phlegmon. In severe cases, the pressure sore turns into sepsis or gas gangrene.

1. Development of purulent pressure ulcers by the type of erysipelas

Erysipelas is a local purulent inflammation in a local area of the skin. The causative agent is hemolytic staphylococcus and other pyogenic microorganisms. Erysipelas occurs in immunocompromised individuals of the older age group, accompanied by toxicosis, hyperthermia.

Symptoms of erysipelas with bedsores:

• the skin in the place of the bedsore is bright red with a noticeable dense cold swelling - the main symptom;
• an increase in body temperature up to 39 ° C;
• headache, weakness, nausea;
• a purulent wound develops;
• exudate from the wound, without treatment enters the bloodstream.

2. Development of purulent pressure ulcers by the type of phlegmonous inflammation

Phlegmon is a diffuse purulent inflammation without clear boundaries. The causative agent is staphylococcus, other pyogenic microorganisms, Escherichia coli. Phlegmon can be localized under: skin, fascia, in the intermuscular space.

Symptoms of phlegmonous inflammation in bedsores:

• glossy swelling without clear boundaries of red color, hot to the touch - the main symptom of the onset of phlegmonous inflammation;
• body temperature up to 40 ° C;
• rapid development of a fistula with purulent or putrid contents.

3. Development of pressure ulcers by the type of septic inflammation

Sepsis or purulent blood poisoning is a continuation of erysipelas or phlegmonous inflammation. The extreme stage of sepsis is septic shock, often pumped by the death of the patient.

Symptoms of purulent septic inflammation in bedsores

Symptoms such as:

• atypicality - a variety of symptoms, the absence of the main (pathognomonic).
• high temperature at the beginning of the process and low at the end;
• rapid development of the process.

With the phenomena of sepsis, they begin to fight in the early stages of a pressure ulcer with the help of antibiotic therapy. Currently, bringing the patient to a septic state is rare, possibly with an immunodeficient state of the patient, insensitivity to antibiotics.

4. Development of pressure ulcers of the type of gas gangrene

Gas gangrene is a severe purulent, putrefactive pathology. The causative agent is a clostridium microorganism, most often clostridium perfringens (soil microorganism). Infection occurs when contaminated soil enters the macerated surface of the bedsore.

Symptoms of gas gangrene with pressure ulcers:

• the sounds of crepitus (crunching) when passing over the damaged area of the skin is a pathognomonic symptom.
• rapid development within six to seven hours;
• skin color is gray-blue;
• the wound is dry;
• strong putrid odor.

Treatment of the skin for bedsores

There are three directions of skin treatment for bedsores

• Hygienic treatment of the skin, to maintain the physiological properties of the skin (moisture, pH of the skin, soften the integument, increase elasticity), remove the physiological secretions of the body (sweat, sebum, epidermal scales), aggressive media of feces (urine and feces) and deodorize the skin;
• Preventive skin treatment to stimulate local blood circulation, restore sensitivity, prevent skin cracking.
• Treatment, the use of drugs in preparative forms (ointment, cream, solution, gel, spray, powder, dusting powder, solution for external use, etc.),

Decubitus solution

In modern surgery, the use of solutions in the treatment of pressure ulcers has somewhat lost its former significance. Meanwhile, simple solutions have been successfully used for many decades in military field surgery to treat wounds and their complications.

• To prevent the development of pressure sores, the following are recommended: 2% camphor alcohol solution, 0.5% ammonia solution, 1-2% tannin solution in alcohol, 1% salicylic alcohol 2-3 times a day.
• Recommended for the treatment of pressure ulcers:
• external solutions - 25% MgSO4 solution, 10% hypertonic NaCl solution with chymotrypsin, 05% aqueous solution of chlorhexidine bigluconate;
• parenteral solutions - intravenously, drip 0.5% metronidazole solution.
• Solutions in any concentration are not recommended for prevention and treatment: iodine, KMnO ₄ - potassium permanganate, brilliant green, hydrogen peroxide.

It is important to monitor the patient's diet. The diet should include foods that contain zinc, iron and other beneficial trace elements. Pressure ulcers are often caused by a lack of iron. They are rich in dairy products, fish, poultry, chicken eggs. The patient should eat more green vegetables and fresh fruits. For those patients whose digestive system does not cope well with meat, broths are an alternative.

On the subject: Prevention of bedsores

Bedsores on the heels, buttocks and tailbone

The usual position of the supine patient. The most vulnerable places for the development of bedsores are the buttocks, coccyx, heels, and sometimes the area of the shoulder blades. Therefore, first of all, during hygienic procedures of the patient, one should pay attention to the indicated areas of the body.

Bedsores on the heels

Unusual, at first glance, localization, however, is common. Several diseases of the heels are known, which, although not associated with bedsores, are proof of the vulnerability of this area of the body, namely: heel necrosis (Haglund-Schinz disease), bursitis, epiphysitis of the heels, and so on.

Causes of bedsores on the heel:

• load when lying on your back;
• thick skin, it is difficult to notice the beginning pathology;
• cracks in the skin of the heels, the likelihood of microbial contamination is increased;
• congestion of the lower extremities - a frequent companion of the elderly, occurs in some diseases (diabetes mellitus, etc.).

Symptoms of pressure sores on the heels

Many sources indicate the absence of precursors of bedsore on the heels. The appearance of a bedsore may be preceded by a white spot, tingling, loss of sensitivity in the heel area.

Preventive actions

Prevention of pressure sores on the heels includes:

• use relief devices for the heels (wedge-shaped pillows, sheepskin, special mattresses);
• stimulate blood circulation (light massage of the calves of the legs), rub in 2% camphor alcohol, change the position of the legs every two hours;
• protect the skin of the heels from microflora, for example, with a colloidal butterfly dressing (Comfil Plus), which creates the effect of a wet sterile chamber. The materials from which the bandage is made, the impregnating composition allows you to leave the bandage on the wound for two to five days.

Treatment of pressure sores on the heels

Treatments and treatments for pressure sores on the heels do not differ from the treatment of pressure sores on other parts of the body. The anatomical features of the location of the pressure ulcer are taken into account.

Bedsores on the buttocks

Bedsores on the buttocks are dangerous consequences. This area is located close to important organs (rectum, hip joint, pelvic organs, nerve nodes and blood vessels innervating the lower extremities), the disruption of which significantly affects the quality of life, in some cases, the preservation of life.

The buttocks have a powerful muscular apparatus that must resist the formation of pressure sores. However, regular contamination of the skin with urine, feces, without proper hygienic treatment, stimulates the development of bedsores. With the formation of a necrotic focus, extensive soft tissue defects are formed that are difficult to treat. Harbingers and symptoms of bedsores on the buttocks are typical.

Preventive actions:

Prevention of pressure sores on the buttocks includes:

• carry out regular hygiene procedures for the buttocks and perineum using washing creams, liquids, sprays; to simplify procedures, use special latex-coated gloves that isolate the hands of the person caring for the patient, do not injure the damaged areas of the patient's skin;
• to prevent diaper rash of the skin of the buttocks and perineum, use absorbent panties, sheets, diapers, diapers, neutral absorbent powders;
• Regularly, every two hours, change the patient's posture, use anti-decubitus mattresses with programmable change in the hardness of the bed and its different parts, use pillows, rollers and other devices to prevent bedsores on the buttocks.

Treatment of pressure sores on the buttocks

In the early stages, Russian-made multifarm napkins or their analogues are recommended. The use of multiferm napkins is indicated for purulent processes with mild to moderate exudation. The exposure time and frequency of the course are indicated on the package.

Treatment of advanced forms of pressure ulcers on the buttocks is carried out taking into account the anatomical features of this part of the body, similar to the treatment of purulent wounds.

Bedsore on the tailbone

This area of the body protrudes somewhat and, when lying down, tightly touches the bones of the coccyx with the bed of the bed. Bedsores on the tailbone are dangerous due to the small muscle layer and the presence of important nerve plexuses in it. The melting of tissues during necrosis damages the nerve endings and provokes a violation of the innervation of the lower body.

Symptoms of a pressure sore on the tailbone

Harbingers and symptoms of a pressure sore on the coccyx correspond to the classical concepts of the development of its pathogenesis. In view of the anatomical proximity of the buttocks and coccyx, preventive measures and treatment of the early stages are identical to those on the buttocks.

How to treat bedsores?

Treatment of pressure ulcers of the second, especially the third and fourth stages should correspond to the treatment of purulent wounds. Purulent wounds are difficult to treat, but over the years of field surgery, a standard treatment algorithm has been developed. Of course, additions and improvements to the treatment are regularly made, however, the goal and objectives of the treatment remained unchanged.

I. In the first phase of pathogenesis

In the first phase, when the pressure sore wound is filled with pus and necrotic tissue, you should:

• ensure the outflow of pus from the wound;
• relieve swelling;
• suppress microbial contamination of the wound.

Revision of the wound, cleaning of the edges from necrotic tissue is performed in a surgical department. For the outflow of pus, drainage tubes are made and regularly revised.

RELATED: List of home remedies for bedsores

Passive drainage can be done at home:

1. For this, the wound is filled with special napkins soaked in compounds that facilitate the outflow of pus. The napkins are changed periodically. As napkins, you can use ordinary bandages, the edges of which do not fall apart into threads. For impregnation of napkins, solutions and ointments are used.

Obsolete medicines: hypertonic solutions of 10% sodium chloride, 3-5% boric acid solution and others. Currently, the use of such solutions is limited due to the low suction force from 4 to 8 hours.

Hydrophobic ointments (liniment, emulsion) based on petroleum jelly (liniment according to Vishnevsky, syntomycin emulsion, tetracycline, neomycin and others). Their disadvantage is that they do not absorb pus, the antibiotics in their composition do not work in full force.

Modern medicines: hydrophilic (water-soluble ointments) - Levomekol, Levosin and other water-soluble compounds. They remove pus from the wound well, within about 20-24 hours. Attention! Use hydrophilic ointments only if there is pus in the wound; in another situation (no pus), these ointments are not effective.

Enzyme therapy is the next method of surgical treatment of purulent wounds (therapy with enzymes that remove pus).

Proteolytic enzymes (trypsin, chymotrypsin, others). To enhance their action, a combination of these or other enzymes with ointments is used, for example, a combination of enzymes and Iruxol ointment.

• Antiseptic solutions for external use. furacilin, hydrogen peroxide, boric acid (currently used to a limited extent). Modern compositions are shown for use - 0.5% solution of iodopyrone, 1% solution of dioxidine.
• Physical treatments. They use traditional methods (UHF, ultrasonic cavitation, oxygenation, vibrophoning, laser therapy and other similar methods)

II. In the second phase

In the second phase, after cleaning the decubitus from pus, healthy tissue is achieved. A healthy scab is a thin layer of dried granulation. A purulent scab is a thick crust of dried pus. Recovery under a purulent scab is impossible!

When healthy granulations appear, treatment is prescribed:

• relieves inflammation;
• protects healthy granulations (healthy tissue) from accidental damage;
• stimulating tissue repair processes.

To relieve inflammation, use:

• ointments (hydrophobic ointments - methyluracilic, troxevasinic, hydrophilic ointments - bepanten and others);
• herbal preparations - aloe juice, Kalanchoe, oil (sea buckthorn, rosehip);
• laser therapy with a therapeutic effect of stimulating tissue epithelialization.

III. In the third phase

In the third phase, regeneration and scarring of the wound process is achieved. They use modern drugs that stimulate epithelialization and scarring of tissues, for example: EDAS-201M, vitamins, immunostimulants. At all phases of pathogenesis, the use of antibacterial agents is allowed, intravenous drip administration of metrogil solution, antibiotics is recommended.

The resulting defects and the consequences of pressure ulcers are treated in a hospital setting.

The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist

Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.