What is a bed sore?

Merriam-Webster’s online Dictionary defines a bed sore as “an ulceration of tissue deprived of adequate blood supply by prolonged pressure —called also decubitus ulcer.” Although descriptive, I do not believe that definition gives a clear enough picture of what a bed sore really is. In our office, someone says decubitus or “pressure ulcer” and we all know what it really means -- dead skin which occurred because excessive, prolonged pressure was put on an area of the skin. This article will provide you with a broad picture of what pressure ulcers and bed sores are, and why you should be concerned about them. While it is an unpleasant topic to discuss, it is much worse to witness the development of bed sores on a loved one which can lead to infection and death.

Why would I even write an article on this unsavory topic?

Because bed sores are a huge concern for residents of long term care facilities. In 1994, the federal government’s Agency for Health Care Research and Quality estimated that 23% of nursing home residents suffered from a bed sore. That means 23% of elderly patients are not moved, or properly cared for such that portions of their skin and surrounding tissue die from lack of adequate blood flow. The number is even more discouraging when you consider that most pressure ulcers are preventable, but if not treated, can be fatal. If I had to guess, I would say about 10% of our wrongful death cases are pressure ulcer cases. Clearly an issue worth discussing.

As federal and state agencies have learned in recent years that pressure ulcers are worthy of national attention, a group called the National Pressure Ulcer Advisory Panel was created to develop national standards for pressure ulcer prevention and treatment. Under recent standards, hospitals and long-term care facilities are provided with a step-by step process on preventing, diagnosing and treating pressure ulcers. We will follow their lead and address these three areas one topic at a time.

Preventing Pressure Ulcers

The federal government has published guidelines on the prevention of pressure ulcers. Read here for the full assessment. In short, the following steps should be followed by the nursing home staff (or home care provider) to prevent pressure ulcers:

• Complete a physical on admission to a facility (including skin condition and wounds).
• Reassess whenever the patient’s condition changes.
• Use a reliable and standardized tool for doing a risk assessment such as the Braden Scale which is available at: www.bradenscale.com/braden.PDF.
• Document risk assessment scores and implement prevention procedures and protocols.
• Assess skin daily.
• Clean skin at time of soiling--avoid hot water and irritating cleaning agents.
• Use moisturizers on dry skin.
• Don’t massage bony prominences (that means tail bones, hips, heels, etc.)
• Protect skin of incontinent patients from exposure to moisture (which means CHANGE the patient often!).
• Use lubricants, protective dressings, and proper lifting techniques to avoid skin injury from friction/shear during transferring and turning of clients (don’t drag skin across a bed, or chair – be careful!).
• Turn and reposition bedbound patients every 2 hours if consistent with overall care goals and use a written schedule for turning and repositioning clients.
• Use pillows or other devices to keep bony prominences from direct contact with each other.
• Raise heels of bedbound patients off the bed -- don’t use donut-type devices.
• Keep head of the bed at lowest height possible.
• Reposition chair or wheelchair bound patients EVERY HOUR. In addition, if the patient is capable have them do small weight shifts every 15 MINUTES.
• Keep the patient as active as possible, encourage mobilization.
• Manage nutrition: Consult a dietitian and correct nutritional deficiencies by increasing protein and calorie intake and provide A, C, or E vitamin supplements as needed.
• Manage Hydration: Offer a glass of water with turning schedules to keep patient hydrated.

Good nutrition, hydration, turning etc. – and the facility should be able to prevent a bed sore from ever forming. Sadly, we see more often than not, over-worked CNAs do not have time to make sure Mrs. Smith is drinking from her water pitcher and making sure she is being turned as required. If possible, constantly remind your loved one/patient of the importance of position changing and drinking water – and if cognitive problems prohibit this type of communication, act as watch dogs to make sure it is getting done!

Diagnosing Pressure Ulcers

As of February 2007, the NPUAP (as mentioned above) has established a system for diagnosing the severity of a pressure ulcer. This system “stages” the ulcer according to various factors. A Stage I pressure ulcer is the least severe and most treatable and stage V is considered an “unstageable pressure ulcer,” very severe. The new definitions are simply stated, as follows:

Stage I – “intact skin with non-blanchable redness…”

Stage II – “partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.”

Stage III – “full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through underlying fascia.”

Stage IV – “full thickness tissue loss with exposed bone, tendon or muscle.”

I know these terms are tricky as they use many medical terms but I implore you to read Stage IV again.

Yes, it says exposed bone! That is why these bed sores are so serious. Failure to prevent one from forming and you are creating a situation where infection, germs, feces etc – can have direct exposure to bone, muscles, blood stream etc. without skin and tissue for protection. Not to mention the pain a stage II – V pressure ulcer would cause.

Treating Pressure Ulcers

Many facilities use what is called the Braden Scale to rate and treat pressure ulcers. The Sale is as follows (Adapted from Ayello & Braden, 2001):

• At risk: score of 15 to 18 - Frequent turning, consider every 2 hour schedule, use a written schedule; Maximize patient’s mobility; Protect patient’s heels; Use a pressure-reducing support surface if patient is bed or chair rest;
• Moderate risk: score of 13 to 14 - Same as above but provide foam wedges for 30 degree lateral position
• High risk: score of 10 to 12 - Same as above but increase the turning frequency ; requires small and more frequent shifts of position
• Very high risk: score of 9 or below - Same as above but use a pressure relieving surface; manage moisture, nutrition, and friction/shear

Well that is not very helpful, is it? Other facilities use specific products for various stages – creams for stage I and II; surgically debriding (or removing dead tissue) for stage III or IV. Each facility may differ but a trend seems to exist across the board. Pressure Ulcers are difficult to properly treat and require additional nursing care, as well as physician time. With low staffing levels at many nursing homes, we frequently find that wounds are not being properly treated, do not heal and the individual suffers serious consequences.

So What Can You Do To Help?

As a family member of someone at risk for bed sores (which is anyone immobile; with diabetes; poor circulation; poor hydration), you should do the following:

• Check the skin yourself – do you see pressure areas? If so – point them out to the nurse on duty. Write down what it looks like – take pictures!
• If a wound exists – ask to see it. Staff may tell the family “we can’t remove the bandage” but you nicely tell them you need to see that wound, and if they won’t remove it – you will.
• Document progression of wounds – if no healing after two weeks – take your loved one to a wound specialist. Don’t just assume the nurse is doing all that is necessary.
• Make sure turning and repositioning is being done. Stay there for 2-3 hours and see if your loved one is repositioned. If not, do it yourself and report it to the nurse.

Any other questions, do not hesitate to contact our office.