Probably some of you know how painful it is – physically and mentally when a familiar person or relative loses their ability or desire to move. He spends more and more time sitting or lying down, and caring for him is becoming more and more difficult. This also leads to the formation of so-called decubitus or bedsores (pressure ulcers).

Unfortunately, the Blocks Hospice often encounters this problem at different stages of the development of bedsores on the skin, so we thought it necessary to tell you more about what bedsores are and how they can grow, if not monitored appropriately treated, and what care they require. Thanks to Associate Professor Dr Nikolay Yordanov, consultant in anaesthesiology and resuscitation, pain treatment and palliative care, today we will pay special attention to one part of the topic. His many years of experience and work in the team of Blocks Hospice will help you make the right decisions in caring for a loved one.

Introduction

Trophic wounds, bedsores (abrasions), open surfaces of tumors involving the skin, varicose (trophic) wounds, and other types of difficult-to-heal wounds should not be underestimated because:

  • Create conditions for the development of an infection that can affect the whole body and endanger the life of the patient (e.g. sepsis);
  • Lead to the appearance of a foul (smelly) odour;
  • They cause pain, which can lead to complete dependence of the patient on others;
  • They can become a source of bleeding, which in some cases can be life-threatening (e.g. bleeding from decaying tumours of the head and neck);
  • Increase the requirements for caregivers and increase the volume of care provided;
  • Deteriorate the quality of life of both patients and their family members;

Decubitus ulcers (bedsores)

Decubitus ulcers, or so-called bedsores (abrasions), are not just minor skin irritations or abrasions but conditions that require active prevention and aggressive treatment. Once they appear, they can progress and become very large and/or deep and become a severe medical problem. Bedsores develop due to ischemia of the skin and subcutaneous tissues due to pressure, which has the body’s weight when lying or sitting on areas where the bone is closer to the skin surface – heels, buttocks, hips, head and hip.

The constant pressure leads to the closure of the micro arterioles and a subsequent reduction in blood flow to the tissues located in the area above the bone, resulting in their oxygen supply being disrupted. If not stopped in time, the pressure can lead to irreversible damage and the development of necrosis (death of the cells that make up the affected tissues). The skin may tolerate hypoperfusion (reduced blood flow) for a period not exceeding 60 minutes. Factors that affect the ability of tissues to tolerate hypoxia and respectively to delay the development of bedsores are “internal” (originating from the body itself) and “external” (originating from the environment). Internal factors are:

  • Reduced mobility of the patient (locally advanced disease, paralysis, etc.);
  • Pathological conditions that lead to a decrease in tissue oxygen supply (anemia, vascular pathology);
  • Age-related changes in the skin;
  • Deteriorated nutritional status of the patient and the development of cachexia.

External factors include those arising from the environment, such as:

  • Friction forces between the body and the mats;
  • The presence of moisture (sweating, wound secretions, urine);
  • Resistance of the skin to splitting (the ability of the skin to maintain its integrity in specific conditions of pressure, moisture, cachexia, etc.);

Prevention of bedsores requires the highest level of care. Bedridden patients require regular repositioning and the use of aids to reduce pressure on vulnerable areas. The skin should be regularly protected from abrasion, moisture and splitting. In high-risk areas, a thin hydrocolloid film or hydrocolloid dressings should be applied. Early involvement of a specialist in the care of difficult-to-heal wounds is recommended to support the training of the patient and caregivers, carry out the ongoing assessment, and make the right choice of dressings according to the unique circumstances arising from the patient in terms of comfort, cost, replacement time, prognosis and wound characteristics.

The deeper the bedsores, the more complex and slow their healing, and when they reach the underlying bone, in-depth, active surgery is required to treat them.

Bedsores are divided into the following several stages.

Stages (Degrees)

In its development, bedsores go through several stages (degrees), determined by the wound’s depth and the type of tissue affected. This, in turn, is important in determining treatment, the volume of care and prognosis. Timely diagnosed and actively treated, bedsores have a relatively good prognosis. The skin usually recovers within a few days, and the wounds are relatively painless. It can be understood that the skin heals when the damaged area decreases in size, and the appearance of fresh pink tissue is noticed at its edges. Without timely treatment, the process progresses.

Stage I (Degree)

This is the initial stage. Bedsores have affected only the surface layer of the skin. A harbinger of the coming changes is so-called non-fading erythema (redness that does not go away with the cessation of pressure).

Symptoms

Most often, these are pain, burning or itching. The affected area feels different from the surrounding skin: it is often described as firmer or softer, warmer or cooler.

Most often, the skin is reddened and slightly discoloured skin in the usual places for bedsores. If the patient has a darker skin colour, the discoloured area is more difficult to notice. The characteristic of this stage is that under pressure, the skin does not change colour and does not become lighter, nor does it regain its colour when the force ceases, which means that the blood supply in the affected area suffers.

Behaviour

The first and most important thing to do with any bedsore is to stop the pressure in the affected area. This is done by changing the body’s position or with the help of special aids, such as foam pads, pillows or mattresses.

The skin should be well hydrated and clean. The affected area is cleaned with mild soap and water and dried carefully.

A balanced diet high in protein, intake of vitamins A, E and C, and trace elements – iron and zinc- help maintain the integrity of the skin. Patients should be encouraged to drink plenty of water.

Recovery time

Full recovery can be expected within a few days if the measures listed above are followed.

Stage ІІ

Then, when the wound has deeply affected the skin. There is a partial loss of skin thickness involving the epidermis and dermis. The bedsores are superficial and resemble abrasion (abrasion) with a shallow crater or blister (fluid blister).

Symptoms

The skin is injured, there is an open wound or a blister filled with clear, sometimes bloody fluid, and in case of infection and pus.

Behaviour

Similarly, in stage I bedsores. The wound is carefully cleaned with saline. The manipulation can be painful, so 30 minutes – 1 hour before the manipulation is necessary to make a premedication with an analgesic (paracetamol, analgin, paracetamol + tramadol or paracetamol + codeine). In very severe pain, strong opioid analgesics (oxycodone, morphine) may be needed. It is good to cover the wound with special bandages and to use transparent fixing patches. The wound should be carefully monitored for the presence of infection – redness, pus, fever). Active medical supervision is required when an infection is detected and, if necessary, a course of antibiotic treatment is needed.

Recovery time

Stage II bedsores usually heal within 3 days to 3 weeks.

Stage ІІI

Wounds at this stage pass through the entire surface layer of the skin and affect the subcutaneous adipose tissue, can reach the muscle layer, but do not engage it in depth. All the skin is lost, including the subcutaneous fat in the affected area. The ulcer may reach but does not pass through the underlying fascia. The ulcer has the appearance of a crater, with or without undermining of adjacent tissues.

Symptoms:

The wound looks like a crater and usually unpleasant smells. There are clinical signs of infection: the skin around the wound is warmer, the wound has reddened edges, the presence of pus and/or secretion is observed. The dead tissue in and around the wound has changed colour to black.

Behaviour

Stage III bedsores require significantly more care. A necrectomy (surgical removal of dead tissue from the wound) may be needed, and antibiotic treatment may be prescribed for an infection.

Recovery time

Stage III bedsores usually heal in no less than 1 month, and sometimes the recovery time can be up to 4 months.

Stage ІV

These wounds are the most serious. The ulcer is deep enough to see the surrounding muscles, ligaments (tendons), and the underlying bone. The presence of necrosis is established, damage to the underlying bones, muscles, tendons, joint capsules is observed. Undermining and involvement of the surrounding tissues are observed.

Symptoms

The wounds are deep and large in area. The skin around the wound has changed colour and maybe necrotic (black). There may be signs of infection – the skin in the infected area is red, swollen and warmer than the surrounding unaffected tissues. There may be wound secretion and the presence of pus.

Behaviour

Stage IV bedsores require urgent medical care and active surgical treatment, and systemic antibiotic therapy in the presence of infection. The risk of developing sepsis is significant.

Recovery time

Stage IV bedsores usually require a lengthy healing period, which in most cases lasts for months and sometimes years.

To these generally accepted stages for classifying the development of bedsores, two more may be added when:

  • The wound “cannot be staged” – when, to establish the depth of the wound and the extent of the damage, specialized treatment is required;
  • “Suspected deep tissue damage” – when the surface of the skin looks like bedsore from stages I and II, but the changes in the underlying tissues are like in stages III and IV.

In the next article, we will continue the topic of bedsores, talking more about how to treat them, the probability of their healing, and wound prevention.

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