Bedsores
Bedsores, more properly known as pressure ulcers or decubitus, are lesions caused by unrelieved pressure to any part of the body, especially portions over bony or cartilaginous areas. Although completely treatable if found early, without medical attention, bedsores can become life-threatening.
Signs and symptoms
Bedsores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of
, has defined each stage as follows:
Stage I.
Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.
Stage II.
At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.
Stage III.
By the time a pressure ulcer reaches this stage, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.
Stage IV.
In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.
If you use a wheelchair, you're most likely to develop a pressure sore on:
- Your tailbone or buttocks
- Your shoulder blades and spine
- The backs of your arms and legs where they rest against the chair
- The back or sides of your head
- The rims of your ears
- Your shoulders or shoulder blades
- Your hipbones, lower back or tailbone
- The backs or sides of your knees, heels, ankles and toes
Many people shift in their chair during meetings, fiddle with the radio when driving, turn a dozen times in their sleep. Every day, without thinking, they make hundreds of subtle postural adjustments that help stave off problems arising from inactivity. But for people immobilized by paralysis, injury or illness, those problems — including bedsores — are a constant threat.
Pressure sores usually result from sustained pressure on your body. They're especially common in areas that aren't well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows. Because your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur.
In some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, crumbs in your bed, wrinkled clothing or sheets, a chair whose tilt is slightly off — even perspiration, which can soften skin, making it more vulnerable to injury.
Other causes of pressure sores include:
- Friction. Frequent shifts in position are the key to preventing pressure sores. Yet the friction that occurs when you simply turn from side to side can damage your skin, making it more susceptible to pressure sores.
- Shear. This occurs when your skin moves in one direction, and the underlying bone moves in another. Sliding down in a bed or chair or raising the head of your bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as your tailbone where skin is already thin and fragile.
Bedsores are easier to prevent than to treat, but that doesn't mean the process is easy or uncomplicated. Still, although wounds can develop in spite of the most scrupulous care, it's possible to prevent them in many cases.
The first step is to work with your nurses and doctor to develop a plan that you and your caregiver(s) can follow. The cornerstones of such a plan include position changes along with supportive devices, daily skin inspections and a maximally nutritious diet.
Position changes
Changing your position frequently and consistently is crucial to preventing bedsores. It takes just a few hours of immobility in a wheelchair or bed for a pressure sore to begin to form. For that reason, experts advise shifting position every 15 to 30 minutes that you're in a wheelchair and at least once every two hours, even during the night, if you spend most of your time in bed. If you can't move on your own, a family member or caregiver must be available to help you.
A physical therapist can advise you on the best ways to position yourself in bed, but here are some general guidelines:
- Avoid lying directly on your hipbones. On your side, lie at a 30-degree angle.
- Support your legs correctly. When lying on your back, place a foam pad or pillow — not a doughnut-shaped cushion — under your legs from the middle of your calf to your ankle. Avoid placing a support directly behind your knee — it can severely restrict blood flow.
- Keep your knees and ankles from touching. Use small pillows or pads.
- Avoid raising the head of the bed more than 30 degrees. A higher incline makes it more likely that you'll slide down, putting you at risk of friction and shearing injuries. If the bed needs to be higher when you eat, place pillows or foam wedges at your hips and shoulders to help maintain alignment.
- Use a pressure-reducing mattress or bed. You have many options, including foam, air, gel or water mattresses. Because these can vary widely in price and effectiveness, talk to your doctor about the best choice for you. For some people, a low-air-loss mattress may provide enough support. But more expensive and technologically sophisticated beds may be needed for people who have recurring pressure sores or who are at very high risk.
All wheelchairs need cushions that reduce pressure and provide maximum support and comfort. Various cushions are available, including foam, gel, and water- or air-filled cushions. Although they may help relieve pressure, cushions and other devices don't prevent pressure sores from forming or replace the need to change your position as often as recommended.
Skin inspection
Daily skin inspections for pressure sores are an integral part of prevention. Inspect your skin thoroughly at least once a day, using a mirror if necessary. Some experts suggest examining your skin twice a day or with every repositioning. A family member or caregiver can help if you're not able to do it yourself.
If you're confined to bed, pay special attention to your hips, spine and lower back, shoulder blades, elbows and heels. When you're in a wheelchair, look especially for sores on your buttocks and tailbone, lower back, legs, heels and feet. If you see skin damage or any sign of infection such as drainage from a sore, a foul odor, and increased tenderness, redness and warmth in the surrounding skin, get medical help immediately.
Nutrition
A healthy diet is important in preventing skin breakdown and in aiding wound healing. Unfortunately, the people most likely to develop pressure sores are also often the most malnourished.
If you're ill, recovering from surgery or living with paralysis, you may have little appetite and eating may be physically difficult. Yet it's essential to get enough calories, protein, vitamins and minerals. A dietitian can help devise an eating plan that caters to your food preferences while supplying necessary nutrients. These measures also may help:
- Try smaller meals. If you feel full after eating only a small amount, try eating small meals more frequently when you do get the urge to eat. If you never seem to feel hungry, it's often helpful to eat according to a schedule rather than to rely on appetite.
- Take advantage of the times when you feel your best. Eat a larger meal when you're hungry. Many people have their best appetite in the morning, when they're rested.
- Limit fluids during meals. Liquids can fill you up and prevent you from eating higher calorie foods. It may help to drink most of your liquids 30 to 60 minutes before or after you eat. Don't restrict your intake of water overall, however. It helps keep skin soft and supple.
- Consider pureed or liquid meals. If swallowing is difficult, emphasize soups, pureed foods or nutritional supplement drinks, which provide protein and calories but require little or no preparation. It may be easier for you to drink rather than to eat something.
- Consider protein alternatives. If meat isn't appealing to you, consider other high-protein foods such as cottage cheese, peanut butter, yogurt and custards. Beans and nuts also are good protein sources but may be hard to digest.
- Find a comfortable position. Raise the head of your bed to a comfortable level while you eat.
- Don't rush. Allow sufficient time for meals, and if you need assistance, don't let your caregiver rush you.
Although you may need assistance with many aspects of your care, you can take control of some important preventive measures, including:
- Quitting smoking. Ask your doctor about the most effective way to stop smoking. Tobacco use decreases oxygen to your skin, robs your body of vitamin C and slows wound healing.
- Exercise. Daily exercise improves circulation, builds up vital muscle tissue, stimulates your appetite and strengthens your body overall. A physical therapist can recommend an exercise program tailored to your needs.
- Support. Your physical and emotional well-being depend on having a strong support system. Don't be afraid to ask for help with daily tasks or for emotional support.
If you have a loved one in a nursing home, hospital or other care facility, check that person's skin condition, weight and general care every time you visit. If you notice any sign of pressure sores or neglect, alert the nursing staff and attending physician or nursing home director immediately. You and other family members are in the best position to monitor and assess a loved one's condition.
Credit: National Institute of Health.