Family members with someone in long-term care need to be knowledgeable and vigilant about decubitus ulcers — the dreaded bedsores.
Also called pressure sores, pressure ulcers or decubitus ulcers, bedsores are skin wounds that result from prolonged pressure on the skin that’s in contact with a bed or wheelchair. Bedsores are painful, take a long time to heal and are often a precursor of life-threatening complications such as skin and bone infections.
The human body is designed to be in constant movement, even while we sleep. We constantly shift positions, always unconsciously readjusting ourselves in bed, at the computer station, watching TV or whatever active or inactive pursuit engages us.
Bedsores form in the areas where we have the least padding of muscle and fat, especially right over a bone. The tailbone (coccyx), shoulder blades, hips, heels and elbows are common sites for bedsores. Total immobility, even for as little as 12 hours, can cause bedsores.
Circulation is impeded when blood flow slows or stops in the compressed area between bone and the surface of a bed or wheelchair. When the tissue is deprived of oxygen and nutrients, the skin can die in as little as half a day, although the evidence may not be obvious for days or even weeks.
When surgery, injury to the spinal cord, or an illness causes immobility the pressure of the immobilized body on certain areas can break down the skin. In bed, the most dangerous areas are the tailbone or buttocks and the heels. The toes, ankles, knees, hipbones, shoulders and shoulder blades, and even the rims of the ears are also at risk.
In a wheelchair, the locations at highest risk are again the tailbone and buttocks, as well as shoulder blades and the spine, and the backs of arms and legs where they touch the chair.
Problems such as arthritis or injury that make movement painful or impossible increase the probability of bedsores. Diabetics and paraplegics who have no sense of feeling in their feet are especially at risk.
Two additional causes of bedsores are shear and friction:
Good skin hydration with lotion can be helpful, and of course it is important to keep all skin clean and dry.
Age is the greatest risk factor for bedsores; the older the person, the more vulnerable their skin. In an immobilized older person, even a small skin tear, which could easily occur during routine activities such as transferring from bed to a wheelchair, might quickly develop into a bedsore. Other risk factors include smoking, lack of pain perception, urinary or fecal incontinence, malnutrition, dementia and other medical conditions such as diabetes.
Bedsores develop in stages:
Often the situation that precipitates a bedsore makes it very challenging to treat. Conditions such as diabetes, thin skin and immobility make healing difficult. As noted, Stage I bedsores will usually disappear if repositioning is prompt and consistent. A physician’s written orders can help this happen.
Stage II, when a wound is present, calls for a multi-disciplinary approach coordinating the physician, the nurses, the aides and perhaps a physical therapist. Sometimes a social worker can help manage the personal care services provided. A careful analysis of how the wound was precipitated will help determine treatment. A change of bed, cushioning, skin care and/or clothing may be effective. Support surfaces are particularly important, and special padding such as sheepskin or waffle foam can help. Low-air-loss beds use inflatable pillows for support; air-fluidized beds suspend the patient on an air-permeable mattress that contains millions of silicon-coated beads.
There are several things that can aid with healing:
Even with the best medical care, bedsores may require surgery. Healthy tissue may be taken from one part of the body to use in reconstructing the damaged area. Recovery is long and arduous with frequent complications. Prevention is still the best treatment.
The highest percentage of people with bedsores are in nursing homes. Some bedsores may have been acquired in the hospital, and then persisted when the person transferred to a skilled care facility. The prevalence varies from study to study, and facility to facility, but anywhere from 3 to 28% of the people in a nursing home may have bedsores.
It’s a chicken and egg situation: which came first, the bedsore or the environment? Often frail older people come to live in a nursing home because this injury is so difficult to prevent and treat at home. Sometimes the conditions that necessitate living in a nursing home, such as advanced dementia or paralysis, create the bedsore.
Federal regulations are particularly stringent about preventing, documenting, and treating bedsores. The website www.medicare.gov (click on “Compare Nursing Homes in Your Area“) gives the ratings for every nursing home and tells you the percentage of residents with bedsores and how that compares with the national average.