DECUBITUS ULCERS: THE QUIET KILLER

EXPLANATION OF DECUBITUS ULCERS

A decubitus ulcer is a pressure sore or what is commonly called a "bed sore". It can range from a very mild pink coloration of the skin, which disappears in a few hours after pressure is relieved on the area, to a very deep wound extending to and sometimes through a bone into internal organs. These ulcers, as well as other wound types, are classified in stages according to the severity of the wound.

MECHANISM OF FORMATION

The usual mechanism of forming a decubitus ulcer is from pressure. However it can also occur from friction by rubbing against something such as a bed sheet, cast, brace, etc., or from prolonged exposure to cold. Any area of tissue that lies just over a bone is much more likely to develop a decubitus ulcer. These areas include the spine, coccyx or tailbone, hips, heels, and elbows, to name a few. The weight of the person's body presses on the bone, the bone presses on the tissue and skin that cover it, and the tissue is trapped between the bone structure and bed or wheelchair surface. The tissue begins to decay from lack of blood circulation. This is the basic formation of decubitus ulcer development.

NURSING CARE, PREVENTION AND TREATMENT OF DECUBITUS ULCERS

The common areas of decubitus ulcer formation and prePrevention consists of changing position every 2 hours or more frequently if needed. This 2-hour time frame is a generally accepted maximum interval that the tissue can tolerate pressure without damage. Prevention also consists of protection and padding to prevent tissue abrasion, and maintaining hydration, nutrition and hygiene.vention is a basic nursing principle.

TREATMENT

The treatment for a decubitus ulcer involves keeping the area clean and removing necrotic (dead) tissue, which can form a breeding ground for infection. There are many procedures and products available for this purpose. The use of antibiotics, when appropriate is also part of the treatment. Some deep wounds even require surgical removal or debridement of necrotic tissue. In some situations amputation may be necessary.

The second portion of the treatment involves removing all pressure from the involved area(s) to prevent further damage of tissue and to promote healing. Frequent turning is mandatory to alleviate pressure on the wound and to promote healing. Along with cleaning, removal of dead tissue, and alleviating pressure, the individual must have increased nutrition to allow for proper healing of the wounds. Without all of these elements being in place, the wounds will not heal and, in fact, will quickly worsen.

PREVENTION

The basic treatment of decubitus ulcers is prevention. Prevention cannot be stressed too strongly. To this end, there are any number of devices designed to protect and prevent the formation of decubitus ulcers. The decision of which device to use is based on the location and severity of the wound. These devices may be a Medicare/Medicaid/Insurance-covered item when medically necessary. Most insurance's will cover any needed device, material, or equipment necessary to prevent and treat decubitus ulcers. Prevention is the most humane and cost effective approach to care.

STANDARDS OF CARE

It remains true that decubitus ulcers are generally considered preventable and the development of decubitus ulcers is evidence of some form of neglect [nutrition, hydration, positioning, infection control, etc]. Many paralyzed or terminal individuals with very poor nutrition can remain free of decubitus ulcers. This is accomplished by good patient care often being provided by family members and non-licensed hired caregivers. Professional medical personnel generally provide only a minimum amount of medical assistance. Prevention is achieved by diligent care.

Decubitus ulcers need to be viewed as a

preventable injury, not an excusable one!

STAGES OF WOUNDS

Wounds are often categorized according to severity by the use of stages. The staging system applies to burn wounds, Decubitus and several other types of wounds.

STAGE I

This stage is characterized by a surface reddening of the skin. The skin is unbroken and the wound is superficial. This would be a light sunburn or a first degree burn as well as a beginning Decubitus ulcer. The burn heals spontaneously or the Decubitus ulcer quickly fades when pressure is relieved on the area.

STAGE I The key factors to consider in a Stage I wound is

what was the cause of the wound and how to alleviate pressure on the area to prevent it from worsening. Improved nutritional status of the individual should also be considered early to prevent wound worsening. The presence of a Stage I wound is an indication or early warning of a problem and a signal to take preventive action.

Treatment consists of turning or alleviating pressure in some form or avoiding more exposure to the cause of the injury as well as covering, protecting, and cushioning the area. Soft protective pads and cushions are often used for this purpose. An increase in vitamin C, proteins, and fluids is recommended. Increased nutrition is part of prevention.

STAGE II

This stage is characterized by a blister either broken or unbroken. A partial layer of the skin is now injured. Involvement is no longer superficial.

STAGE II

The goal of care is to cover, protect, and clean the area. Coverings designed to insulate and absorb as well as protect are used. There is a wide variety of items for this purpose.

Skin lotions or emollients are used to hydrate surrounding tissues and prevent the wound form worsening. Additional padding and protective substances to decrease the pressure on the area are important. Close attention to prevention, protection, nutrition, and hydration is important also. With quick attention, a stage II wound can heal very rapidly.

STAGE III

The wound extends through all of the layers of the skin. It is a primary site for a serious infection to occur.

STAGE III

The goals and treatments of alleviating pressure and covering and protecting the wound still apply as well as an increased emphasis on nutrition and hydration.

Medical care is necessary to promote healing and to treat and prevent infection. This type of wound will progress very rapidly if left unattended. Infection is of grave concern.

STAGE IV

A Stage IV wound extends through the skin and involves underlying muscle, tendons and bone. The diameter of the wound is not as important as the depth. This is very serious and can produce a life threatening infection, especially if not aggressively treated. All of the goals of protecting, cleaning and alleviation of pressure on the area still apply. Nutrition and hydration is now critical. Without adequate nutrition, this wound will not heal.

STAGE V

This is an older classification and not now used in all areas. A stage 5 wound is a wound that is extremely deep, having gone through the muscle layers and now involves underlying organs and bone. It is difficult to heal. Surgical removal of the necrotic or decayed tissue is the usual treatment. Amputation may be necessary is some situations.

POSSIBLE NURSING DIAGNOSES:

Impaired Tissue Integrity related to decubitus ulcer(s)

Acute Pain related to decubitus ulcer(s) Impaired Tissue Integrity related to impaired

mobility Risk for Impaired Tissue Integrity related to

Nutrition: less than body requirements Risk for Impaired Tissue Integrity related to

Deficient Fluid Volume

BRADEN SCALE

The Braden Scale for Predicting Pressure Sore Risk was developed during a Robert Wood Johnson Teaching Nursing Home project and while writing an NIH proposal to study pressure ulcer risk factors. The Braden Scale was initially tested for reliability and validity and these results were published in Nursing Research in 1987.The Braden Scale has been disseminated widely, translated into many languages, and is used to some extent around the world-wide.