Risk and stages of development of bedsores, how to treat?

The development of bedsores on the body complicates the treatment of patients in intensive care units, geriatric departments, as well as during the period of rehabilitation at home, after heart attacks, strokes, with spinal paralysis, complex fractures of the limbs, spinal injuries, coma, other pathologies, with a forced stay of a person in a monotonous pose.

What are bedsores?

Bed sores are a pathological change in the skin, subcutaneous tissue, muscles, bones, and other tissues of the body, developing as a neurotrophic disorder, the causes of which are a violation of innervation, blood and lymph circulation of a local area of ​​the body, with prolonged contact with a hard surface.

Brief description of pathological changes on the body:

• develop on the side of the body adjacent to a hard surface;

• characterized by staging of pathogenesis, begin with circulatory stasis, in the absence of treatment, end with neurotrophic necrosis of the wet or dry type, sepsis or gas gangrene;

• most rapidly, within a day, develop in malnourished patients, with congestion in cardiovascular insufficiency;

• localized on protruding areas of the body, the most typical lesions:

• when the patient is positioned on the back, the area is affected (sacrum and coccyx, buttocks, spinous processes of the spine, area of ​​​​the shoulder blades, heels);

• when the patient is positioned on the stomach, the area is affected (knee joints, iliac crests, protruding surface of the chest);

• when the patient is positioned on his side or half-sitting, the area (sciatic tubercles) is affected;

• rarely localized on the back of the head and folds of the mammary glands.

Specific localization of bedsores on the skin: under plaster casts, in places of tight fit of materials that do not penetrate moisture (oilcloth diapers, rubber tubes), folds of bed linen, bandages, etc.

Specific localization of bedsores on the mucous membranes: under dentures, with prolonged drainage of the urethra – on the urethra, with prolonged catheterization of blood vessels – on the mucosa of the vessels.

The first signs of bedsores

• Subjective sensations that the patient can report to caregivers, while being conscious and maintaining pain sensitivity of body parts:

• tingling on the skin in places where pressure sores are likely to develop, is associated with stagnation of biological fluids (blood, lymph) that feed the nerve endings;

• loss of sensation (numbness), after about 2-3 hours in this area of ​​the body.

• Visible signs of an incipient bedsore that caregivers must know:

• stagnation of peripheral blood and lymph, initially in the form of venous erythema of a bluish-red color, without clear boundaries, with localization at the point of contact of the bone, muscle protrusions of the body with the bed, the intensity of skin staining: from barely noticeable to saturated;

• desquamation of the epidermis of the skin with the preliminary formation of purulent vesicles or without them.

These are signs of an incipient pressure sore. It is urgent to take measures to prevent further aggravation of the pathology.

What to do to eliminate the first symptoms of a bedsore?

To do this:

• change the position of the patient every two hours, if there are no contraindications, it is recommended to use special pillows to change the position of the limbs and body relative to the surface of the bed, forming gaps between the skin and the bed;

• monitor the level of the patient’s headboard, the headboard should be lower or flush with it;

• regulate the moisture content of the patient’s skin with hygiene products (washing cream, foam, solution, spray, you can warm baths (it is forbidden to use hot water), do these procedures twice a day, with uncontrolled defecation, remove contaminants as quickly as possible;

• remove excess moisture from the skin and skin folds (water, liquid food residues, urine, wound exudate, sweat) using special absorbent pads, diapers, wipes, towels, films;

• regularly re-lay the bed or change bed linen at least once a day;

• do not do an intense massage, light stroking of skin areas with signs of stagnation is allowed, carry out this procedure carefully, without friction, especially in areas with close bones;

• use anti-decubitus mattresses of a balloon or cellular type, equipped with special silent compressors to maintain and change the rigidity of its base, with adjustable and programmable inflation of different areas.

• use, for patients in wheelchairs, pillows filled with gel foam, air, monitor the change in body position in the chair at least once an hour.

Why are pressure sores dangerous?

Bedsores are pathologies, the treatment of which is best avoided. If this could not be done, then with the formation of foci of skin maceration, the pathogenesis develops very quickly, with the formation of foci of tissue necrosis and is characterized by long-term treatment of a purulent wound. Dangerous outcomes of bedsores. In some cases, bedsores are the cause of:

• extensive excisions of soft tissues and the formation of defects with impaired innervation and blood circulation of the underlying parts of the body,

• amputations of the lower extremities;

• necrotic lesions of the periosteum and bone tissue in the form of osteomyelitis, periostitis;

• depletion of the body’s defenses, complicating the treatment of the underlying disease;

With the development of bedsores by the type of wet necrosis, infection of the wound occurs, with the development of purulent processes (phlegmon, sepsis, gas gangrene).

With the development of bedsores by the type of dry necrosis, a protracted pathogenesis develops with long periods of defect healing.

Causes of bedsores

The reason for the bedsores is as follows. Our body is full of small blood vessels. Through these vessels – capillaries – blood flows to various organs of the body. If there is a squeezing of the blood vessels, then the blood stops flowing to the tissues, as a result of which the tissues become dead.

Also, pressure sores are formed if a wet sheet is often pulled out from under a sick person. When this happens, the blood vessels rupture. It is completely invisible to the human eye. But after the rupture of blood vessels, blood stops flowing to the tissues. Bedsores are formed.

Also, blood vessels can break if a person cannot, for example, walk and constantly slides himself to take a different position.

Risk Factors for Pressure Sores

It is noticed that bedsores develop in bedridden patients at different times. In medical institutions, to systematize the assessment of risk factors for the development of bedsores, the Norton, Braden or Waterlow scales are used. At home, they do not matter. On the basis of these criteria, risk factors associated with care errors and the individual characteristics of the patient, suitable for home use, are formulated.

1. Factors associated with errors in the organization of patient care:

• untidy bed, re-made less than once a day;

• rare change of underwear to dry and clean;

• neglect of hygiene procedures (treatment of the body with special solutions, drying, massage of body parts where possible without additional trauma to the bedsore);

• hard, uneven surface.

2. Factors associated with the individual characteristics of the patient’s condition:

• elderly age;

• exhaustion or vice versa obesity of the patient;

• diseases of the cardiovascular system;

• diseases associated with impaired innervation of the body (including strokes);

• disorders associated with changes in metabolic processes in the body (diabetes mellitus, impaired water-salt metabolism or the usual restriction in drinking);

• unbalanced nutrition or lack of protein food in the diet, protein dystrophies (protein metabolism disorders);

• the patient’s condition (coma, dementia, other) in which he does not control defecation, urination.

In addition, factors provoking the occurrence of bedsores include smoking, diabetes, lack of water and little nutrition, being overweight or, on the contrary, very small weight, urinary and fecal incontinence, dirty skin, crumbs and small objects in bed, an allergic reaction to drugs skin care, folds, seams, buttons on underwear, as well as injuries and diseases of the spinal cord and brain, sweating at elevated temperatures.

Stages and degrees of bedsores

The pathogenesis of bedsores is characterized by stages of development. There are four stages of pathogenesis.

I pressure ulcer stage

Visually determined by venous erythema at the site of skin contact with a foreign surface. Venous erythema is the result of obstructed outflow of blood from a local area.

How to distinguish venous erythema from arterial hyperemia and bruising?

• Difference from arterial hyperemia:

• the color of venous erythema is red-cyanotic, the color of arterial erythema is bright red;

• the local temperature of venous erythema corresponds to the temperature of the skin or slightly lower, the local temperature of arterial hyperemia is a warm area of ​​the skin at the site of temperature measurement.

• Difference from a bruise:

• red-bluish color of the skin in the place of pressure of the finger does not change (bruising)

• a similar color of the skin at the site of pressure turns pale (venous hyperemia).

Venous hyperemia (erythema) of the protruding bone areas of the human body adjacent to foreign surfaces, without violating the integrity of the skin, is the most important symptom of a first stage bedsore.

II pressure ulcer stage

Visually determined by the thinning of the epidermis – the upper layer of the skin, followed by peeling, the formation of bubbles. The pathogenesis develops as follows: venous stasis provokes tissue malnutrition, innervation of a body area, excess fluid in the skin, causes swelling (maceration) and rupture of epidermal cells.

Superficial skin lesions in the form of thinning and peeling of the epidermis, integrity violations, maceration (moisturizing) are the most important sign of the second stage of the bedsore.

III pressure ulcer stage

Visually defined as a wound with suppuration (contamination with microflora) or without suppuration.

Involvement in the pathogenesis of deep layers of skin tissues, subcutaneous tissue, muscles with a purulent type of inflammation and incipient processes of necrosis (tissue death) are the most important sign of the third stage of pressure sores.

IV pressure ulcer stage

Visually defined as a local cavity or a defect formed as a result of decay (necrosis), along the edges of the cavity is filled with defect walls on which purulent inflammation continues.

A necrotic cavity and its expansion due to inflammation of the walls is the most important sign of the fourth stage of a bedsore.

On different parts of the body, there may be different stages of bedsores.

Purulent bedsores

Suppuration of the area of ​​the bedsore begins from the second stage, develops in the third and fourth, after the seeding of the wound with staphylococci, streptococci, and other pyogenic microorganisms of the area.

A common path for the development of a purulent bedsore is erysipelas and phlegmon. In severe cases, the bedsore turns into sepsis or gas gangrene.

1. The development of purulent bedsores by the type of erysipelas

Erysipelas is a local purulent inflammation on a local area of ​​the skin. The causative agent is hemolytic staphylococcus and other pyogenic microorganisms. Erysipelatous inflammation occurs in persons with weakened immunity, the older age group, accompanied by toxicosis, hyperthermia.

Symptoms of erysipelas with bedsores:

• the skin at the site of the bedsore is bright red with a noticeable dense cold swelling – the main symptom;

• increase in body temperature up to 39 ° C;

• headache, weakness, nausea;

• a purulent wound develops;

• exudate from the wound, without treatment, enters the bloodstream.

2. The development of purulent bedsores by the type of phlegmonous inflammation

Phlegmon is a diffuse purulent inflammation without clear boundaries. The causative agent is staphylococcus aureus, other pyogenic microorganisms, Escherichia coli. Phlegmon can be localized under: the skin, fascia, in the intermuscular space.

Symptoms of phlegmonous inflammation in bedsores:

• glossy swelling without clear red borders, hot to the touch – the main symptom of the onset of phlegmonous inflammation;

• body temperature up to 40 °C;

• rapid development of a fistula with purulent or putrid contents.

3. The development of bedsores by the type of septic inflammation

Sepsis or purulent infection of the blood is a continuation of erysipelas or phlegmonous inflammation. The final stage of sepsis is septic shock, often resulting in the death of the patient.

Symptoms of purulent septic inflammation in bedsores

You can identify symptoms such as:

• atypicality – a variety of symptoms, the absence of the main (pathognomonic).

• high temperature at the beginning of the process and low at the end;

• rapid development of the process.

With the phenomena of sepsis, they begin to fight in the early stages of a bedsore with the help of antibiotic therapy. At present, bringing the patient to a septic state is rare, possibly with an immunodeficient state of the patient, insensitivity to antibiotics.

4. The development of bedsores by the type of gas gangrene

Gas gangrene is a severe purulent, putrefactive pathology. The causative agent is Clostridial microorganism, most often Clostridium perfringens (soil microorganism). Infection occurs when infected soil gets on the macerated surface of the bedsore.

Symptoms of gas gangrene in bedsores:

• sounds of crepitus (crunching) when carried over the damaged area of ​​the skin is a pathognomonic symptom.

• rapid development within six to seven hours;

• gray-blue skin color;

• the wound is dry;

• strong putrid smell.

Skin treatment for bedsores

There are three areas of skin treatment for bedsores.

1. Hygienic treatment of the skin to maintain the physiological properties of the skin (humidity, pH of the skin, softening of the integument, increasing elasticity), removal of physiological secretions of the body (sweat, sebum, epidermal flakes), aggressive stool media (urine and feces) and skin deodorization;

2. Preventive treatment of the skin, to stimulate local blood circulation, restore sensitivity, prevent skin cracking.

3. Therapeutic treatment, the use of drugs in formulations (ointment, cream, solution, gel, spray, powder, powder, solution for external use, other),

Solution for treatment of bedsores

In modern surgery, the use of solutions in the treatment of bedsores has somewhat lost its former importance. Meanwhile, simple solutions have been successfully used for many decades in military field surgery for the treatment of wounds and their complications.

It is important to monitor the nutrition of the patient. The diet should include foods that contain zinc, iron and other beneficial trace elements. Bedsores often form from iron deficiency. They are rich in dairy products, fish, poultry, chicken eggs. The patient should eat more green vegetables and fresh fruits. For those patients whose digestive system does not cope well with meat, broths are suitable as an alternative.

Bedsores on the heels, buttocks and coccyx

The usual position of the patient lying on his back. The most vulnerable places for the development of bedsores are the buttocks, coccyx, heels, and sometimes the area of ​​​​the shoulder blades. Therefore, first of all, during the hygienic procedures of the patient, attention should be paid to these areas of the body.

Bedsores on the heels

Unusual, at first glance, localization, but common. Several diseases of the heels are known, which, although not associated with bedsores, are evidence of the vulnerability of this area of ​​the body, namely: heel necrosis (Haglund-Shinz disease), bursitis, epiphysitis of the heels, and so on.

Causes of pressure sores on the heel:

• load when lying on the back;

• thick skin, it is difficult to notice the beginning pathology;

• cracks in the skin of the heels, increased likelihood of microbial contamination;

• stagnation of the lower extremities is a frequent companion of the elderly, occurs in some diseases (diabetes mellitus and the like).

Symptoms of bedsores on the heels

Many sources indicate the absence of harbingers of pressure sores on the heels. The appearance of a bedsore may be preceded by a white spot, tingling, loss of sensation in the heel area.

Preventive measures

Prevention of bedsores on the heels includes:

• use unloading devices for heels (wedge-shaped pillows, sheepskins, special mattresses);

• stimulate blood circulation (light massage of the calves of the legs), rub 2% camphor alcohol, change the position of the legs every two hours;

• protect the skin of the heels from microflora, for example, using a colloidal butterfly dressing (Comfil Plus), which creates the effect of a wet sterile chamber. The materials from which the bandage is made, the impregnating composition allow you to leave the bandage on the wound for two to five days.

Treatment of bedsores on the heels

Means and methods of treatment of bedsores on the heels do not differ from the treatment of bedsores on other parts of the body. Take into account the anatomical features of the location of the bedsore.

Bedsores on the buttocks

Bedsores on the buttocks are dangerous consequences. This area is located close to important organs (rectum, hip joint, pelvic organs, nerve nodes and blood vessels innervating the lower extremities), the disruption of which significantly affects the quality of life, in some cases, the preservation of life.

The buttocks have a powerful muscular apparatus, which must resist the formation of bedsores. However, regular contamination of the skin with urine, feces, without proper hygienic treatment, stimulates the development of bedsores. When a necrotic focus is formed, extensive soft tissue defects are formed that are difficult to treat. Harbingers and symptoms of bedsores on the buttocks are typical.

Preventive actions:

Prevention of bedsores on the buttocks includes:

• carry out regular hygiene procedures of the buttocks and perineum using washing creams, liquids, sprays, to simplify the procedures, use special latex-coated gloves that isolate the hands of the person caring for the patient, do not injure damaged areas of the patient’s skin;

• to prevent diaper rash of the skin of the buttocks and perineum, use absorbent underpants, sheets, diapers, diapers, neutral absorbent powders;

• Regularly, every two hours, change the position of the patient, use anti-decubitus mattresses with a programmable change in the rigidity of the bed and its different parts, use pillows, rollers and other devices to prevent pressure sores on the buttocks.

Treatment of bedsores on the buttocks

In the early stages, Russian-made multi-farm wipes or their analogues are recommended. The use of multiferm wipes is indicated for purulent processes with mild to moderate exudation. The exposure time and frequency of the course are indicated on the package.

Treatment of advanced forms of bedsores on the buttocks is carried out taking into account the anatomical features of this part of the body, similar to the treatment of purulent wounds.

Decubitus on coccyx

This area of ​​the body protrudes somewhat and, when lying down, is in close contact with the bones of the tailbone with the bed of the bed. Bedsores on the coccyx are dangerous due to the small muscle layer and the presence of important nerve plexuses in it. Melting of tissues during necrosis damages the nerve endings and provokes a violation of the innervation of the lower body.

Symptoms of a bedsore on the coccyx

Harbingers and symptoms of pressure ulcers on the coccyx correspond to the classical ideas of the development of its pathogenesis. In view of the anatomical proximity of the buttocks and coccyx, preventive measures and treatment of early stages are identical to those on the buttocks.

How to treat bedsores?

Treatment of bedsores of the second, especially the third and fourth stages should correspond to the treatment of purulent wounds. Purulent wounds are difficult to treat, but over many years of field surgery, a standard treatment algorithm has been developed. Of course, additions and improvements to treatment are regularly made, but the goal and objectives of treatment have remained unchanged.

I. In the first phase of pathogenesis

In the first phase, when the bedsore wound is filled with pus and necrotic tissues, one should:

• ensure the outflow of pus from the wound;

• remove swelling;

• suppress microbial contamination of the wound.

Revision of the wound, cleaning the edges of necrotic tissues is performed in the conditions of the surgical department. For the outflow of pus, drainage tubes are made and they are regularly inspected.

Passive drainage can be carried out at home:

1. To do this, the wound is filled with special napkins, impregnated with compounds that promote the outflow of pus. Change napkins periodically. As napkins, you can use ordinary bandages, the edges of which do not fall apart into threads. Solutions and ointments are used to impregnate napkins.

   Outdated medicines: hypertonic solutions 10% sodium chloride, 3-5% boric acid solution and others. At present, the use of such solutions is limited due to the low suction power of 4 to 8 hours.

   Hydrophobic ointments (liniments, emulsions) on a vaseline basis (liniment according to Vishnevsky, synthomycin emulsion, tetracycline, neomycin and others). Their disadvantage is that they do not absorb pus, the antibiotics in their composition do not work in full force.

   Modern medicines: hydrophilic (water-soluble ointments) – Levomekol, Levosin and other water-soluble formulations. They well remove pus from the wound, for about 20-24 hours.

   Attention! Use hydrophilic ointments only if there is pus in the wound; in another situation (no pus), these ointments are not effective.

2. Enzyme therapy is the next method of surgical treatment of purulent wounds (therapy with pus-removing enzymes).

   Proteolytic enzymes (trypsin, chymotrypsin, others). To enhance their action, a combination of these or other enzymes with ointments is used, for example, a combination of enzymes and Iruksol ointment.

3. Antiseptic solutions for external use. furatsilin, hydrogen peroxide, boric acid (currently used to a limited extent). Modern formulations are shown for use – 0,5% iodopyrone solution, 1% dioxidine solution.

4. Physical methods of treatment. Traditional methods are used (UHF, ultrasonic cavitation, oxygenation, vibrophoning, laser therapy and other similar methods)

II. In the second phase

In the second phase, after cleaning the bedsore from pus, the appearance of healthy tissues is achieved. A healthy scab is a thin layer of dried granulations. A purulent scab is a thick crust of dried pus. Recovery under a purulent scab is impossible!

When healthy granulations appear, treatment is prescribed:

• relieving inflammation;

• protecting healthy granulations (healthy tissues) from accidental damage;

• stimulating tissue repair processes.

To relieve inflammation use:

• ointments (hydrophobic ointments – methyluracil, troxevasin, hydrophilic ointments – bepanten and others);

• herbal preparations – aloe juice, Kalanchoe, oil (sea buckthorn, rosehip);

• laser therapy with a therapeutic effect of stimulating tissue epithelialization.

III. Into the third phase

In the third phase, regeneration and scarring of the wound process are achieved. They use modern drugs that stimulate epithelialization and scarring of tissues, for example: EDAS-201M, vitamins, immunostimulants. At all phases of pathogenesis, the use of antibacterial agents is allowed, intravenous drip administration of metrogil solution, antibiotics is recommended.

The resulting defects and the consequences of bedsores are treated in a hospital.