Bedsores, also known as pressure sores, pressure ulcers, or dermal ulcers, are deep ulcers that form when pressure is exerted over bony areas of the body, restricting circulation and leading to the death of cells in the overlying tissue. When pressure cuts off blood flow, the skin area starved for oxygen first becomes red and inflamed, then sore. Even when the blood flow is only partially interrupted, friction and other kinds of damage to the outer skin layer can cause ulcers. Ill-fitting clothing, wrinkled bedding, or shoes rubbing against the skin may contribute to skin injury.
Bedsores are considered to be a sign of patient abuse and neglect and should be reported to the proper authorities.
In most people, bedsores cause some pain and itching; in people whose senses are dulled, even severe, deep sores may be painless.
Bedsores are categorized by stage. In stage 1, a sore hasn't actually formed; the unbroken skin is simply red. In stage 2, the skin is red and swollen - often with blisters - and the topmost skin layers begin to die. At stage 3, the sore has broken through the skin, exposing deeper levels of skin. By stage 4, the sore extends deeply through the skin and fat and into the muscle. In stage 5, the muscle itself is destroyed. In stage 6, the deepest stage of a bedsore, the bone is exposed, damaged, and sometimes infected. See more about stages 1 through 4 below.
Skin has a rich blood supply that delivers oxygen to all its layers. If that blood supply is cut off for more than 2 or 3 hours, the skin will die, beginning at its outer layer (the epidermis). A common cause of reduced blood flow to the skin is pressure. Normal movement shifts pressure, so that the blood supply isn't stopped for any prolonged period. A layer of fat under the skin, especially over the bony projections, helps pad the skin and keeps the blood vessels from being squeezed shut.
As their name implies, they tend to occur during periods of prolonged bed rest, although wheelchair users also may develop bedsores. People who suffer from bedsores are usually deficient in many nutrients, especially zinc and vitamins A, E, B-2 (Riboflavin), and C, and they often have a high bodily pH.
MoonDragon's Health & Wellness: Acidosis
MoonDragon's Health & Wellness: Alkalosis
Bedsores can occur in people of any age. People who cannot move are most at risk for developing bedsores. This group includes people who are paralyzed, very weak, or restrained. Also at risk are people unable to sense discomfort or pain, signals that normally motivate people to move. Bedsores are particularly common in people who have these conditions:
Aged skin is more likely to deteriorate then a young person's skin. As we age so does the elasticity in our skin. It is similar to an elastic band in an old undergarment losing its elasticity over time. The repeated stretching and washing take a toll on an old undergarment. So does our skin. We all need to pay closer attention to our eating habits. We need to keep well-nourished. We need to make sure that we do not compromise our immune, circulatory, and respiratory systems. And we need to keep properly hydrated by drinking plenty of fluids every day and remain free from diseases.
- Very thin (emaciated).
If you are too thin (emaciated), the lack of oxygen and important nutrients may interfere with your wound's ability to heal. Malnourished people don't have the protective fat layer along with lacking essential nutrients.
- Overweight (obese).
Body type will affect the ability for your wound to repair itself and can be greatly hindered because fatty tissue has a poor blood supply.
- Dead tissue caused by injury or disease.
There are two types of dead tissue found in a wound. The first type is called slough. This can best be described as moist, loose, stringy dead cells, and appears yellow in color. The second type is called eschar and appears as thick, dry leathery-like tissue, and black in color. Dead tissue interferes with the repair process of our wounds and must be removed by a qualified health care provider before healing can take place.
- Unable to move.
People at high risk for the development of pressure ulcers are those people unable to move freely. Spinal cord injury patients, stroke victims, and severe or long-lasting injuries may present certain challenges. Paralyzed, very weak or restrained individuals are at risk for developing bedsores.
Incontinence is the inability for one to control the bladder or bowel. This can interfere with the wound's ability to heal. Incontinence needs to be managed appropriately. If not, this could impair the wound healing process. Ask your health care provider about receiving incontinence care as well as special underclothing, bed protection, and skin care products available to help with this situation.
- Trauma & swelling.
Trauma and swelling interferes with the transportation of oxygen and nutrition from our cells to the wound and thus prolongs the healing process. Healing is slowed, or perhaps even stopped, if there is repeated trauma or deprivation of blood supply from swelling.
If a wound is infected, we must first find out the cause of the infection. A wound infection is present if we can see redness around the wound or the skin around the wound is warm to the touch, if there is thick yellow discharge, a foul odor, a hardening of the skin, and/or a fever. Your health care provider may take a culture of your wound, and perhaps a blood culture, to better determine what is happening.
- Poorly nourished.
Regardless of our age, nutrition plays a vital role in our healing process. Visual appearance of the patient alone does not determine whether we are maintaining an appropriate diet. It is important to receive the appropriate caloric intake. Laboratory values such as protein (essential for the repair of tissue), serum albumin (blood protein level), and hematocrit (the percentage of blood occupied by cells) are indicators that must be assessed and monitored regularly. Anemia (a deficiency in the oxygen carrying component of the blood) can contribute to the development of bedsores.
- Suppressed immune system.
Having a suppressed immune system, either by a disease or medication, can delay the healing process.
- Radiation therapy.
Ulcerations or changes in the skin itself can occur after radiation treatment.
- Chronic diseases.
Many chronic diseases impact the wound healing process. Diabetes is one example. In the insulin-dependent diabetic population, chronic wounds generally heal very slowly, or perhaps not at all. Insufficient amounts of insulin can delay granulation tissue formation (the red beefy healthy tissue in the healing wound). In this case, the caregiver and the provider need to monitor serum glucose levels of the diabetic patient. You will also want to monitor the signs and symptoms of infection, as well.
- Edema (an accumulation of fluid in tissue spaces).
- Confined to bed or wheelchairs.
- Disoriented (mental impairment).
- In prolonged contact with moisture.
Prolonged exposure to moisture - often perspiration, urine, or feces - can damage the skin surface, making bedsores more likely.
- Continuously exposed to dry environment.
Wounds have been found to heal 3 to 5 times faster, and less painful, in a moist (but not wet) environment as opposed to a dry environment. When a wound is continuously exposed to a dry environment (such as air), our cells are not given the ability to move or reorganize, which is part of the healing process. And if nerve endings are exposed in the wound, we will experience pain due to the irritation.
Vascular insufficiencies resulting in decreased blood supply to the lower legs can be one cause leading to wounds and/or ulcers developing on our legs and feet. These would include arterial ischemic ulcers, diabetic ulcers, pressure ulcers, and venous stasis ulcers. It is important to have these identified for proper treatment.
- Subjected to shearing.
When a person slides down in bed, or in a wheelchair, shearing occurs with potential skin damage.
Shearing occurs when the skin moves in one direction while the structures under the skin, such as the bones, remain fixed or move in the opposite direction. This can happen when a person is dragged rather than lifted up in bed, when positions are changed, or when a person slides down in bed or in a wheelchair. Blood vessels become twisted and stretched, causing the tissues being served to lose essential oxygen and nutrients, leading to breakdown. In addition, shearing may cause actual tears in fragile skin. These skin tears are painful, a portal of entry for infectious pathogens, and commonly lead to further breakdown.
Common sites for skin breakdown.
Bedsores (pressure ulcers) are caused by prolonged pressure on an area of the body that interferes with circulation. The tissue first becomes reddened. As the cells die (undergo necrosis) from lack of nourishment, the skin breaks down and an ulcer forms. The resulting pressure ulcers become large and deep. As their name implies, they tend to occur during periods of prolonged bed rest. However, wheelchair users also may develop bedsores.
Pressure ulcers occur most frequently over areas where bones come close to the surface. The most common sites are the:
- Shoulders, shoulder blades.
- Knees (inner and outer parts).
The rubbing of nasal catheters, nasogastric tubes, or urinary catheters can cause breakdown of skin.
People tend to develop pressure ulcers where body parts rub and cause friction. Common sites are:
- Between the folds of the buttocks.
- Under the breasts.
- Abdominal folds.
The rubbing of tubing and other equipment used in the care of ill person over a long period of time can also cause pressure sores.
PREVENTING BEDSORES (PRESSURE ULCERS)
Prevention is the top priority, and deep bedsores can almost always be prevented with intensive nursing care. Because bedsores are far easier to prevent than to cure, everyone participating in a person's care (medical attendants and family members in addition to the nursing staff) has a responsibility to prevent skin breakdown. Established bedsores are painful and life threatening. They lengthen the time spent in hospitals or nursing homes and increase the cost of care. Bedsores, unfortunately, are found more commonly in long-term care facilities (nursing homes and rehab hospitals) than in short-term care institutions or home care. One of the reasons for this is that the patient has less personal care and attention in long-term facilities, who are often short-staffed and can be neglectful of bedridden individuals, letting them lay in their beds without proper turning and safety measures that can help prevent bedsores. Careful daily inspection of a bedridden person's skin can detect early redness. Any sign of redness is a signal that immediate action is needed to prevent skin breakdown. In choosing a facility for a family member, pay special attention to the care of the residents in the facility. If your family member is already in a facility, check them for signs of bedsores or skin breakdown. Report it immediately to the head of the medical or nursing staff and follow up on the report to make sure they are correcting the problem. If not, it would be better to find another facility.
When a person is admitted to a care facility, the nurse will assess the patient's current status and potential for skin breakdown. This assessment gives a baseline against which all future assessment may be measured. The assessment may be described on the patient's chart in words, pictures, diagrams, or as a score. If a nursing diagnosis of actual or "potential impairment of skin integrity" is made, every staff member must make extra efforts to prevent skin breakdown, limit any breakdown that has already occurred, and promote the healing process.
PATIENTS AT RISK TO DEVELOP PRESSURE SORES: Identify any patient at risk to develop pressure sores by assessing the seven clinical condition parameters and assigning a score. Any patient with intact skin, but scoring 8 or greater should having nursing diagnosis "Potential Impairment of Skin Integrity" identified.
Clinical Condition Parameters - Risk of Pressure Sores
Clinical Condition Parameters Score General Physical Condition (Health Problem)
Fair (Major But Stable)
Poor (Chronic/Serious Not Stable)
Level of Consciousness (To Commands)
Alert (Responds Readily)
Lethargic (Slow to Respond)
Semi Comatose (Responds Only To Verbal or Painful Stimuli)
Comatose (No Response To Stimuli)
Ambulant Without Assistance
Ambulant With Assistance
Full Active Range
Limited Movement With Assistance
Moves Only With Assistance
Incontinence (Bowel and/or Bladder)
Occasional (Less than/equal to 2 per 24 hours)
Usually (Greater than 2 per 24 hours)
Nutrition (For Age & Size)
Good (Eats/Drinks Adequately 3/4 Meal)
Fair (Eats/Drinks Inadequately - At Least 1/2 meal)
Poor (Unable/Refuses To Eat/Drink - Less Than 1/2)
Good (Well Nourished/Skin Intact)
Fair (Poorly Nourished/Skin Intact)
Poor (Skin Not Intact)
DEVELOPMENT OF PRESSURE ULCERS (BEDSORES)
Tissue breakdown occurs in four stages. Nursing intervention at each stage can limit the process and prevent further damage. Remember to continue all preventive measures throughout care.
First indication of tissue damage (Stage 1) is redness and heat over a pressure point.
STAGE 1 (STAGE I)
In Stage 1 (Stage I), the skin develops a redness or blue-gray discoloration over the pressure area. In dark-skinned people, the area may appear drier. If after peripheral massage and relief of pressure, the blush has not subsided, it is probably the beginning of a pressure ulcer (bedsore). Usually this stage of ulceration is reversible if the pressure is reduced or removed.
Stage 2 (Stage II) is marked by destruction of the epidermis and partial destruction of the dermis.
STAGE 2 (STAGE II)
In Stage 2 (Stage II), the skin is reddened and there are abrasions, blisters, or a shallow crater at the site. The area around the breakdown site may also be reddened. The skin may or may not be broken. The epidermis alone or both the epidermis and the dermis may be involved. If this stage of involvement is neglected, further and deeper damage occurs.
Stage 3 (Stage III) all layers of skin have been destroyed. A deep crater has formed.
STAGE 3 (STAGE III)
In Stage 3 (Stage III), all the layers of the skin are destroyed and a deep crater forms. The nurse documents the size of the lesion using a commercial scale.
Stage 4 (Stage IV), tissue destruction can involve muscle, bone, and other vital structures.
STAGE 4 (STAGE IV)
In Stage 4 (Stage IV), the ulcer extends through the skin and subcutaneous tissues, and may involve bone, muscle, and other structures. At this stage, the patient will experience fluid loss and pain and is at great risk for infection.
ACTIONS TO TAKE WHEN BREAKDOWN OCCURS
Nursing care actions when skin breakdown occurs include:
- Performing the actions listed in the guidelines to prevent further breakdown.
- Following the care plan exactly.
- Reporting indications of infection, such as fever,odor, drainage, bleeding, and changes in size.
- Keeping the area around the breakdown clean and dry.
- Assisting with baths to keep the area clean.
- The area may be covered with a dry, sterile dressing (DSD). Holding a DSD without causing additional injury is not easy. The skin of some individuals may be sensitive to regular tape. In this case, silk tape, paper tape, cellophane tape, or other hypoallergenic tape may be used. To prevent injury when removing the tape for a dressing change, a saline solution is applied to loosen the tape.
- The patient may be placed on alternating-pressure mattresses or pressure-reducing mattresses or beds.
- In some facilities, open lesions are packed loosely with gauze soaked in a wound gel. The gel keeps the lesions moist, breaks down dead cells, and promotes healing.
- Teflon-coated or petroleum jelly-impregnated gauze has the advantage of not sticking to the healing wound.
- The area may be protected and kept moist by using special dressings. These dressings have a clear plastic covering that permits air to reach the tissues, but also keeps them moist to promote healing. The dressing must extend beyond the wound edge. It is held in place with a frame of either paper or silk tape. The dressing must be changed every 3 to 5 days unless there is leakage or according to facility policy.
- The wounds may be cleaned with saline solution and debrided (dead tissue removed) using instruments and proteolytic enzymes (substances that react with skin proteins) by a qualified health care provider. Chemical agents can be used instead, but they are generally less thorough than a scalpel.
- Deep bedsores are difficult to treat. Sometimes they require transplanting healthy skin to the damaged area. Unfortunately, this type of surgery is not always possible, especially for frail older people who are malnourished. Often when infections develop deep within a sore, antibiotics are given. When bones beneath a sore become infected, the bone infection (osteomyelitis) is extremely difficult to cure and may spread through the bloodstream, requiring many weeks of treatment with an antibiotic.
- For deeper sores, special dressings that contain a gelatin-like material can help new skin grow. If the sore appears infected or oozes, rinsing, washing gently with soap, or using disinfectants such as povidone-iodine can remove the dead and infected material. However, cleansing too harshly slows healing.
- Antiseptic sprays, antibiotic ointments, and dressings are used to control infection.
- Surgery may be needed to close the ulcerated area in severe cases.
Guidelines for Preventing Pressure Ulcers (Bedsores)
- Herbal, Nutritional, & Holistic Recommendations
Patients (and their family members) should be encouraged to participate to whatever extent is possible in their own care. Attentive nursing care is essential in preventing skin breakdown. Remember that it is far easier to prevent pressure ulcers than to heal them.
BLOOD CIRCULATION TO TISSUES
Ensuring adequate circulation to tissues is a major factor in preventing skin breakdown. This can be accomplished by:
- Positioning the patient properly.
- Using mechanical aids.
- Giving back rubs.
- Performing active or passive range-of-motion exercises.
Five basic in-bed positions are used to relieve pressure as the patient's condition permits. Each position must be supported for comfort. The care provider must remember that all patients are able to assume the full range of positions, because of disabilities such as arthritis, contractures, and breathing limitations. Patients who sit in geri-chairs or wheelchairs for long period of time must also change position to relieve pressure.
Patients with special problems require extra care when they are positioned in bed. For example:
- Be sure the patient can breathe properly.
- Remember that a fractured hip is never rotated over the unaffected leg.
- If the patient had a stroke, elevate the weak arm to reduce edema.
- Always maintain proper body alignment.
- The patient with a recent stroke is turned on the unaffected side.
The five basic positions patients assume in bed are:
- Supine position.
- Semisupine position.
- Lateral position.
- Semiprone position.
- Fowler's position.
MoonDragon's Health Information: Patient Positions (Graphic Descriptions)
Mechanical aids are used to reduce pressure. Examples are:
- Sheepskin Pads (or Artificial Sheepskin). These absorb moisture and reduce friction when placed under the patient.
- Foam Pads & Pillows. These are used to bridge areas to reduce pressure. Watch the patient for signs of disorientation that might be caused by the feeling of weightlessness. Adequate fluid intake to prevent urinary stasis must be provided and conscientious range-of-motion exercises must be carried out.
- Protectors. These are for areas such as heels and elbows. They are meant to protect areas that are subject to friction as the patient moves in bed.
- Bed Cradles. Cradles can lift the weight of bedding that must be carefully positioned and may be padded because injury can occur if the resident strikes them.
- Alternating-Pressure Mattresses (Air Mattresses). This type of mattress is used in some facilities. Air pressure is reduced in a different area of the mattress on an alternating basis. The air pressure alteration reduces pressure against the body so that no skin area is continuously subjected to pressure.
Alternating air pressure mattresses overlay. Alternating air pressure in the mattress cells changes the pressure points against the patient's skin and gently massages the skin.
- Flotation Mattresses. This is a water bed with controlled temperature. The weight of the resident's body displaces water so that pressure is consistently equalized against the skin. Sheets should not be tucked tightly over a flotation mattress because this will restrict its function.
- Pillows. Pillows are used in a technique called bridging. In bridging, body parts are supported by pillows so that spaces are left to relieve pressure on specific areas.
Mattress filled with water helps to minimize pressure points on the body.
- Gel-Filled Mattresses. The gel in this type of mattress has a consistency similar to body fat. It allows a more equal distribution of body weight because it conforms to the body contours.
- Special Equipment. Specialized beds or overlays are available for residents who need continuous pressure relief. One type is the "Clinitron" bed. It is filled with a sand-like material. Warm, dry air circulates through the material to maintain an even temperature and support the body evenly.
BEDSORES PRODUCTS & SUPPLEMENTS
Supplements and product for bedsores, also known as decubitus ulcers or pressure sores, are painful sores caused by constant deficiency of blood to tissues over a bony projection that has been subjected to prolonged pressure against an object like a bed, cast, or splint.
Alive! Whole Food Energizer Multi-Vitamin & Mineral with Naturally Occurring Iron (No Iron Added), Nature's Way, 90 Tabs
No other supplement contains more life-giving nutrients than Nature's Way ALIVE! It is better absorbed into your blood stream because its tablets disintegrate up to 5X faster than other leading brands.
Aloe Vera Juice, Herbal Aloe Force, Organically Grown Unprocessed Whole Raw Aloe Vera, 33.8 fl. oz.
Herbal Aloe Force Re-Natures the cells, tissues, glands, organs and all systems of the body to function as originally designed.
Aloe Vera Skin Gel, Herbal Aloe Force, Organically Grown Unprocessed Whole Raw Aloe Vera, 4 fl. oz.
Can keep your skin looking clean, clear, smooth, toned, hydrated and glowing with health. Can also reduce the appearance of fine lines, wrinkles and sun damage.
Antibiotic, Natural, Support Tincture, 100% Organic, 2 fl. oz.
Use this natural antibiotic to support the immune system.
Antiseptic / Sinus Formula Tincture, 100% Organic, 2 fl. oz.
Use for acne, bed sores, disinfectant, infection, measles, open sores and ulcers, poison ivy/oak, psoriasis, rectal itch, skin disorders, skin eruptions, and sore throat.
Black Ointment, All Natural, Nature's Way, 2 oz.
Nature's Way Black Ointment is a time tested herbal formula made with herbs traditionally used to dry and draw external wounds. This is an excellent herbal wound care product.
Burt's Bees Doctor Burt's Res-Q-Ointment, 0.6 oz.
Burt's Res-Q Ointment will soothe and comfort life's bumps and bruises with the green magic of Mother Nature's herbal medicines.
Colloidal Silver Salve, SilvaSolution, 2 oz.
SilvaSolution Colloidal Silver Salve no contains added homeopathics that add a benefit that will enhance the SilvaSolutions effectiveness.
Comfrey Leaf / Herb Skin Poultice, 2.5 oz.
Comfrey leaf contains allantoin, which promotes the growth of connective tissue, bone, cartilage, and is easily absorbed through the skin.
Comfrey Leaf Powder, 100% Organic, 4 oz. Bulk
One of the most well-known healing plants, especially for its ability to heal tissue and bone.
Manuka Honey Bio Active, 10+, 500 g
Comvita Bio Active 10+ Manuka Honey contains a high level of antibacterial activity not found in other honeys. For digestive health and to assist the digestive process.
Multiflora Honey, 100% Pure New Zealand Honey, 1.1 lb.
Pure New Zealand Honey is made with the help of wild flowers to produce a rich natural taste that is all its own.
Myrrh Herbal Poultice with Comfrey Leaf, All Natural, 2.5 oz.
Used for Bedsores, Chicken Pox, Cuts, Disinfectant, and Skin Eruptions.
Omega 3-6-9- Oil, Mega EFA Blend, Lime Flavored, Nature's Way, 1350 mg, 90 Softgels
Omega 3-6-9 Oil Mega EFA Blend is the most complete daily source of Omega 3,6,9 fatty acids for healthy skin, joints, and cardiovascular function.
Pascalite Bentonite Healing Powder, 16 oz.
Pascalite is used in soap and toothpaste, applied as a poultice to insect bites, sunburns, infections, cold sores, canker sores and acne, and as a suppository for hemorrhoids. Users found it a potent skin cleanser and conditioner, drank it for heartburn and ulcers.
Sea Buckthorn Seed Oil, 100% Natural, 500 mg, 60 Softgels
A rare source of vitamin E, Sea Buckthorn Oil also provides other vitamins including Vitamins A, C, D, K, etc, carotenoids, flavonoids, phytosterols, amino acids, serotonin and 28 trace elements: zinc, iron, calcium, magnesium, selenium, iodine, etc.
Super Multi-Vitamin & Multi-Mineral, Pure Vital Earth, 98% Bio-Available for Absorption, 32 fl. oz.
Super Multi-Vitamin and Mineral has the power to replace almost everything in your vitamin cabinet. Because Super Multi is sweetened with healthy zylitol and stevia there are no unwanted spikes in blood sugar that contribute to fat storage.
Tea Tree Oil Antiseptic Ointment, 2 oz.
A 100% natural Tea Tree Oil antiseptic ointment that combines a therapeutic dose of pure Tea Tree Oil with the absorption powers of Australian Eucalyptus Australiana Oil and Lavender Oil.
Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 Vcaps
Nature's Way Vitamin C with Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.
Witch Hazel (Hamamelis virginiana), C/S Powder, 4 oz. Bulk
Witch Hazel can be taken internally for diarrhea and hemorrhage or externally as a rinse or gargle for sore throats.
Witch Hazel Tincture, 100% Organic, 2 fl. oz.
Witch Hazel can be taken internally for diarrhea and hemorrhage.
HerbalRemedies: Bedsores Information
HerbalRemedies: Bedsores Supplements & Products
PRODUCTS FOR PATIENT CARE & BEDSORES
HiTemp UR Medical Sheepskins
Heel Protectors.com - Heel and Elbow Protectors
Hill-Rom - Beds & Surfaces Products
Nursing Home Abuse Attorney Information
Injuryboard.com - Bedsores Lawsuit News: Find Attorneys for Injuries
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MoonDragon's Health & Wellness - Bedsores Guidelines
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Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
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-- by Phyllis A. Balch, James F. Balch - 4th Edition
Prescription for Herbal Healing: The A-To-Z Reference To Common Disorders
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The Complete Guide to Natural Healing
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