Decubitus Ulcer - Staging, Symptoms, Pictures,Treatment, Prevention and Care
What is Decubitus ulcer?
Bed sores, pressure ulcers, and decubitus ulcers refer to the same problem. This is a condition that usually occurs to people who lay in bed for long hours or to bedridden patients. The pressure exerted on the skin and bone by the individual’s weight against a surface is the primary cause for a decubitus ulcer. Shear force or friction created when moving the patient in the bed can precipitate the formation of an ulcer. Moisture on the bony areas can exacerbate the developing decubitus ulcer. An accompanying humidity of the room or place that a person stays in can contribute to this state. The bony areas of our bodies are quite vulnerable for pressure ulcer formation. The elderly are most at risk for developing pressure ulcers. Patients who are under comatose for a long time are also susceptible for bed sores, especially if a medical practitioner neglects his responsibility preventing pressure ulcers. Individuals who do not protect themselves from pressure ulcers, those who have a sedentary lifestyle, and are unable to change positioning while lying in bed can develop decubitus ulcer at the sacral area (base of the spine). This is not only limited at the sacrum but also at elbows, knees, and ankles. If prompt treatment is done readily, worsening of the condition can be prevented. This has been quite an issue in medicine and hospital care. Since the primary goal of the medical practitioners is to promote health, not add another problem.
According to an epidemiological study, a great number of bed sores occur to elder people, those who are 70 years old. It has been noted that an estimated of 28% of reported pressure ulcers develops in patients in nursing homes. Bed sores are also noted to be a direct cause of death to those with neurological problems and fall to 7-8% of its cases. Those who stayed in the hospital started to develop pressure ulcers are reported to have the highest incidence rate. Recurrence is not doubtfully possible too for patients even under treatment.
Skin breakdown is a sign for a developing decubitus ulcer. Keen observation on highly at risk areas such as the bony parts should be done. The sacral area or back area is the most common site for the development of a bed sore. In the beginning, the sore would start with redness that may eventually get worse. Gradually, when not identified, it forms into a small lesion. A blister will develop that can open up because of the continuing pressure. The end stage would be formation of a crater or a punch-like indention on the skin with accompanying redness and a swelled border. Other affected areas are over the bony structures to the skin such as the elbow, heels, hips, ankles, shoulders, and back of the head.
Proper staging was done in order for prompt classification with accompanying treatment. The classification system below was modified by the National Pressure Ulcer Advisory Panel. This was designed to describe the involvement and depth of the pressure sore as observed by a simple physical examination.
In this stage, the skin is observed as intact but there are signs of an appearing lesion/ulceration. The area when touched is blanchable (when pressed the redness will disappear) erythema. Eventually, the area may appear white when ischemia (absence/restriction of blood supply) follows. When relief is found immediately; the resolution for the impending ulceration is attained. The area is also warm to touch. This is the first phase of tissue destruction that can develop to the next stage if not promptly taken care of.
The affectation of the epidermis of our skin is this stage. There is partial involvement of the dermis too. The developing bed sore is in a form of abrasion, blister or superficial ulceration.
The third stage now involves a thick layer of the skin that would extend into the subcutaneous tissue layer. The underlying fascia is not affected but the lesion developed at this stage would manifest itself as a crater. Since subcutaneous tissues have a poor blood supply, healing process is not readily attained once the bed sore is at this stage.
The last stage of decubitus ulcer is the worst phase of all. It involves the deepest part of our protective skin, extending into our muscles, joints, tendons and even the bones. Because of this, the possibility of developing osteomyelitis (bone infection) is high. This can be very painful on the part of the patient.
In addition to these four stages, the possibility of an “unstageable” pressure sore is there. This may be because of the deep tissue injury that cannot be seen by the naked eye. People with dark skin are also difficult to assess. Obese patient who has overlapping skin layers may have a developing pressure ulcer without knowing.
One of the primary responsibilities of medical practitioners is to avoid adding disabilities or injuries to the patient. Preventing the development of a pressure ulcer is very vital and may reflect the nurse or the loved ones’ ability to take good care of their patients. In case of patients that cannot move about or move out from the bed, we need to practice strict turning of patients at least every two hours. Monitoring the patient’s condition is a must too. Checking the bony prominences of the patient is a step ahead from decubitus ulcer development. For bedridden patients, regular shifting of pressure areas should be done along with placing cushion from time to time. Other institutions, they use water beds or inflated beds for patients in order to relieve the pressure on the back. There are also specifically prepared mattresses for patients in order to relieve pressure or reduce friction unlike ordinary mattresses. The prominent areas of the body are specifically treated with these pressure-distributive mattresses.
We need to eliminate the cause of decubitus ulcer by identifying it first. Pressure should be stabilized and reduced. The preventive measures are also helpful in this process. The use of those mattresses mentioned above is great in the treatment process. The use of these support devices establishes a good turnout for treating the bedsore.
Once the ulcers are in the late stages, proper wound care should be observed. Cleansing the area should be practiced. The famous Dakins solution is made to assist in the treatment. Silvadene, Sulfamylon, hydrogels, xerogels, and vacuum-assisted closure sponges are recommended for decubitus ulcers.
In cases of infected bedsores, we need to identify the presenting symptoms of the patient. The manifestations such as fever, pain, redness, swelling, and purulent discharges should be given attention. Treat the symptoms by giving analgesics, antipyretics, and antibiotics for the infection. Application of antiseptics can readily avoid worsening of the patient’s ulcer.
Surgical intervention is necessary for the removal of tissues that have necrotized. Debridement is specifically done to remove the tissues that may be a reservoir of bacteria which have accumulated on the ulcer. These tissues may have necrotized and should be removed immediately to avoid further damage. This can either be done in the bedside, depending on the extent of severity. Consent is a necessity before doing this task.
The nutritional status of the patient is very important in the evaluation process and in the treatment course. Additional dietary supplements are provided to attain optimum health. In order to facilitate wound healing, a high protein diet is prescribed to patients. Other nutritional supplements include arginine, glutamine, vitamin A, vitamin B complex, vitamin E and C, magnesium, manganese and zinc.
Home care is necessary for discharged patients. It is important that we educate the family members especially the person who will be taking care of the patient. Encourage the relative of the proper nutrition and diet necessary. Wound dressing should be demonstrated to the caregiver, and a return demonstration should be followed so to evaluate understanding of the instructions. Further instructions include no massaging of the affected area. As it may be requested by the patient, massaging the area can only worsen the condition and further damage the tissues under the skin. Instruct the caregiver to seek medical help when the decubitus ulcer is found to be progressing to a severe state. Signs of impending infection are the following and should be taught to the family members or the caregiver: foul smelling ulcer, redness and tenderness around the ulcer, and swelling.