Introduction

A bedsore is a skin condition that develops due to prolonged pressure on the soft tissue of the body, thereby disrupting the adequate flow of blood to that region, causing soreness and tissue damage. They are typically, although by no means exclusively, prevalent amongst bed-ridden patients; hence the name bedsore. Anyone who is confined to stay in one position for an extended period of time is at risk of developing bedsores; these include people who are bed- or wheelchair-ridden, people with an illness or decreased mental capacity and people who have lost the sensation to feel pain. Bedsores are also called pressure ulcers, pressure sores, and decubitus ulcers.

The Agency for Healthcare Research and Quality (AHRQ) defines bedsores as: "A [bedsore] is an injury usually caused by unrelieved pressure that damages the skin and underlying tissue. Bedsores range in severity from mild (minor skin reddening) to severe (deep craters down to muscle and bone)".

In 2006, 503,300 bedsore cases were reported in American hospitals alone, which is an 80% increase from 2003. What's even more alarming is that 90% of these hospitalizations were due to another primary cause of illness and bedsores were just a resulting complication.

Bedsores affect millions of people yearly. They are mostly preventable and are often termed a "hospital–acquired" condition because they are commonly the direct result of hospitalization or some debilitating condition. They can be prevented by carefully following standards of nursing care, both at home and in the hospital.

Causes and Complications

Pressure, friction and shear

 The three main causes of bedsores are pressure, friction and shearing.

Pressure is the gravitational weight of the body as it pushes down against the skin. Typical places for bedsores to develop due to the body's pressure are on bony prominences where the bone is close to the surface of the skin. Places of bony prominence are elbows, buttocks, heels, ankles, tailbone, shoulder blades, lower back, and the back of the ear.

Bedsores are also caused by shearing. Shearing is caused when layers of skin move in the opposite direction of the bone. A classic example of shearing is when a patient is propped in bed with the bed-rest at an elevation greater than 30 degrees; this angle causes the tailbone to jut out and "shear" the skin underneath. The bedsore develops as a result of the skin sticking to the surface of the bed, while the bones slide and protrude.

 Friction can also cause bedsores. Friction is when anything rubs against the body-for example an external device such as a hearing aid rubbing into the back of the ear. Bedsores due to friction can occur when a patient is dragged in bed, or in a chair.

Bedsore Stages

There are 4 identifiable stages of bedsores.

Stage I is invoked when there is persistent redness of skin which does not subside even when pressure is relieved. The redness is due to a skin condition called erythema, whereby the skin does not receive adequate oxygen and degenerates, thus causing soreness. Stage I is treatable relatively easily.

Stage II is when the pressure has spread to between the epidermis and the dermis of the skin. At this point it is still superficial and may be termed a blister or an abrasion. Stage II sores can also be healed fairly quickly following quick and appropriate treatment.

Stage III is invoked when the tissue below the dermis of the skin is damaged. Stage III sores are treated as wounds and involve considerable care and attention.

Stage IV is when severe skin loss occurs and when the wound spreads to the muscle, bone, tendons and even joints. Stage IV bedsores can be fatal if not treated immediately. People with Stage IV sores also have a higher incidence of developing them again.

Complications

Some complications that may be a direct result of untreated or un-subsided bedsores are:

§         Cellulitis: where the skin's connective tissue gets infected

§         Infection: where the infection spread to the joints and bone, rendering them unusable

§         Gangrene: where the tissue dies and causes nerve damage

§         Sepsis: where harmful bacteria enter the bloodstream via a bedsore

§         Cancer: where cells die as a result of carcinogens

Bedsore Risk Assessment

Who is at risk?

 There are certain medical conditions that put people at a higher risk of developing bed sores. These conditions are dementia, diabetes, stroke, obesity, low body mass, malnutrition, vascular disease and terminal illness.

Bedsores may be further exacerbated by physical conditions such as reduced mobility or immobility (such as paralysis caused by a stroke), excess moisture (due to urinary incontinence or sweating) and skin dehydration.

Bedsores are also more common in the elderly (especially above 65 years), people with sensory disability, comatose patients, and patients with a history of developing bedsores.

How to identify risk level?

There are many different tools developed to identify at-risk patients and rate them according to no risk, at risk and high risk criteria. Among the most common tools are the Norton and Braden Scales, which attempt to quantify a given set of criteria relating to a patient's mobility, activity level, mental and physical condition, moisture control, sensory perception, nutrition, friction and shear.

These tools are particularly helpful to the novice clinician in determining a patient's risk level for developing bedsores. The tools are used by experienced practitioners as well to determine the level of risk since it can be easily quantified following a thorough physical examination.

Skin assessment

A skin assessment is a visual exam done of the entire body and especially areas of bony prominence where bedsores may develop. The assessment consists of looking for redness which does not go away when the area is rubbed or pressure is relieved from it - this is an early indicator of a possible bedsore developing.

It is slightly harder to perform this visual assessment on people with dark skin. If the patient is coherent and mentally sound, he/she may be able to pinpoint a developing bedsore because of pain in the area or a slight change in temperature of the affected area since bedsores often feel warmer or cooler to the touch. An alternative is to use high-resolution ultrasound to detect bedsores in people with dark pigmented skin. 

Bedsore Prevention Strategies

Regular skin assessment and risk re-evaluation

Since bedsores are largely preventable and are often not a primary cause of hospitalization but rather a resulting complication, extreme care should be taken to detect and treat them as early as possible. This involves identifying people who are at risk of developing them, and then following up with regular skin assessments and risk evaluations. The AHRQ recommends that once a patient has been identified of being at risk, he/she should undergo daily skin assessment tests and his/her risk level should be constantly monitored. Furthermore patients should be re-evaluated after prolonged time spent on a hard surface, such as an examination table.

Early identification

Early detection involves reducing and managing tissue load effectively. Tissue load is the body's ability to withstand pressure and is dependent on many factors such as the condition of the skin and the patient's nutrition and diet. Once a bedsore has been detected in the early stages, care revolves around relieving pressure from the sore point, reducing the amount of time that pressure is being applied to the sore point and improving the condition of the skin and the body to deal with such pressure. 

Skin optimization and care

A person's skin is an elastic organ, capable of stretching, healing and containing a degree of suppleness and flexibility. The elasticity of skin depends on many factors such as a person's age, nutrition, diet, and body mass. The healthier the skin, the better the chance of preventing or recovering from bedsores is.

Once a patient has been identified as being at risk, several strategies may be implemented to improve the skin's ability to withstand pressure:

§         Skin should be kept dry, but not flaky. Excess moisture and excessive dryness are equally harmful, so the skin's moisture levels must be maintained at optimal and comfortable levels.

§         Nutrition and diet for the patient must include plenty of water, fiber, and essential minerals and vitamins such as Vitamins A, B, C, E and zinc.

§         Although it may seem like an obvious solution, skin massage over bedsores and bony prominences is discouraged and deemed harmful by the AHRQ.

 Reducing mechanical load: positioning and transferring techniques

The most obvious way to prevent bedsores for an immobile patient is to frequently re-position them. However care must be taken while moving a patient so as not to damage fragile skin. While re-positioning, it is important to keep in mind the following:

§         The frequency of re-positioning depends on the daily skin assessment

§         Frequency may be increased if bedsore shows no signs of improvement

§         When re-positioning, the body's weight should never rest on an area of bony prominence

§         Whenever possible the bed-rest should be kept at its lowest elevation or below 30 degrees

§         When transferring a patient from one bed to another, a sail cloth should be used to reduce friction. During transfer, a patient should be gently lifted, not dragged across beds.

 

Moisture control

Moisture weakens the skin's ability to withstand pressure. The skin's integrity can be compromised by moisture resulting from urine or fecal incontinence, by excessive sweating or due to wound drainage. Excess moisture should be cleaned immediately and the skin should be dried with a gentle, non-harsh cleansing agent. 

 Apart from being uncomfortable when wet, it is important that a patient be kept dry for hygiene purposes because clean, comfortable skin has a lower chance of developing infections.

If incontinence is a regular problem, then the patient should be advised continence management. This can take place via a catheter inserted to collect urine, or by the use of underpads and briefs which are designed to absorb excessive moisture.

Similar to excessive moisture is the problem of excessively dry or flaky skin. Excessive dryness also reduces the skin's flexibility and increases chances of bedsores. To reduce dryness, the patient's room should be kept at an optimal humidity level and moisturizers should be applied on the patient's skin.

Diet and nutrition

A good nutrition plan contains an adequate supply of calories, protein and iron. When these diminish, a patient is often more prone to develop bedsores. Therefore it is of vital importance that a patient's diet and nutritional needs be constantly monitored and kept at optimal levels. Aside from regular eating, a patient may also be subscribed nutritional supplements to meet any deficiencies.

Mobility and rehabilitation

When a patient's health and long-term therapy guidelines allow, it is quite beneficial to embark on a mobility and rehabilitation program. Such a program may involve the use of exercise, physiotherapy, physical training, weight shifts, and motion exercises to improve strength, flexibility and coordination skills.

An important part of rehabilitation is making lifestyle changes, such as quitting smoking. Smoking harms the skin's integrity and therefore puts it at risk for developing bedsores.

Wound care and infection control

It's very important to ensure that bacteria in a developing bedsore do not reach unmanageable proportions. Once a bedsore becomes infected with bacteria, healing becomes that much more difficult to achieve spontaneously. Therefore it is essential that any wounds resulting from bedsores be controlled and cleaned as soon as possible and according to the stage the bedsore is in.

Debridement involves the removal of dead or damaged tissue from a wound and must be carried out to ensure healing of the remaining tissue.

Antibiotics and antiseptics are recommended to control bacteria and bring down the infection.

It is also important to note the kind of dressing used to cover bedsores. Gauze pads are the traditional coverings, but recent research suggests that non-gauze coverings are better at containing moisture, and therefore at helping the bedsore heal faster.

Support surfaces and pressure-relieving devices

Since all pressure cannot be reduced simultaneously, effective bedsore management is aimed at optimal redistribution of pressure. And the use of support surfaces is aimed at redistributing pressure in the body.

Support surfaces are often divided into three different categories: static or non-electric devices such as air, foam or fiber mattresses; dynamic electrical devices such as low-air-loss mattresses; and air-fluidized beds.

The AHRQ recommends the use of soft objects between the support surface and the area of skin with bony prominences. AHRQ suggests that:

§         Pillows and cushions should be used between bony prominences and support surfaces.

§         Doughnut-shaped devices should be avoided at all costs since they might cause bedsores rather than prevent them.

The use and suitability of the various support surfaces depends upon the stage the bedsore is in, the cost of the support surface and the risk factor of the patient. Although there are various schools of thought on which support surface is the best, they are all of the same opinion when it comes to using a support surface: a specialized support surface is always better than using a standard hospital mattress!

Standards of Continuous Care

The ultimate goal of caring for a patient with bedsores or one who is likely to develop them, is to educate all who will be involved in the care and rehabilitation of such a patient. This list may include health care professionals (doctors, nurses) as well as family and friends. In fact the success of a bedsore management program depends on a coordinated approach between all those who will be caring for the patient, including the patient himself/herself.

The following items should be included in any educational program to manage and prevent bedsores:

§         Causes of bedsores

§         Risk assessment of patient

§         Skin assessment

§         Reduction of mechanical load and the use of support surfaces

§         Skin care and nutrition

§         Positioning techniques and their active demonstration

§         Documenting bedsore management accurately and consistently across the board