Decubitus Ulcers

The diagnosis of bedsore, at first glance, may not seem terribly alarming; however, without proper treatment a bedsore can advance rapidly and even lead to death due to infection. According to the Mayo Clinic website, Christopher Reeves died from the complication of a bedsore (http://www.mayoclinic.com/health/bedsores/DS00570). While bedsores, also called decubitus ulcers, can be extremely difficult to heal in the advanced stages, if detected early the treatment is minimal and the pressure sore will heal relatively quickly. b. What is a decubitus ulcer?

A decubitus ulcer has multiple names including pressure sore, pressure ulcer, and the most common name of bedsore. According to The American Heritage College Dictionary, a bedsore is "a pressure-induced ulceration of the skin of persons confined to bed for long periods of time" (Pickett, 2002, pp. 126). While this is accurate, it is a rather limited definition. A decubitus ulcer is a "localized breakdown and ulceration of skin due to interference with its blood supply", usually occurring "over a bony prominence...that is subjected to continuous pressure" (Marieb & Hoehn, 2006, pp. 171). It is common in multiple individuals, not just those who are confined to bed, such as those who have paralysis, use a wheelchair, or simply anyone who is unable to change positions, such as someone who was in a serious accident. c. How are they described?

Decubitus ulcers are described based on their severity and are classified in one of four stages. Stage I pressure sores are superficial and immediately recover once the pressure is relieved from the sight (http://www.mayoclinic.com/health/bedsores/DS00570). These are the most common and easiest to correct; however, without proper care pressure sores even in stage I will progress rapidly and become difficult to heal. In stage II the sores are now an open wound in which some skin loss has already occurred in the epidermis, the dermis or both (http://www.mayoclinic.com/health/bedsores/DS00570). With prompt treatment the sores in stage II will heal relatively quickly. Stage III bedsores are deep, crater-like wounds that extend through the entire integument system and into the muscle (http://www.mayoclinic.com/health/bedsores/DS00570). The affected tissue is either severely damaged or completely destroyed in stage III. The most serious bedsores are classified as stage IV. In this stage there is a large loss of skin, severe damage to the muscle and bone, and can even affect supporting structures like tendons and ligaments (http://www.mayoclinic.com/health/bedsores/DS00570). This stage is not only exceptionally difficult to heal, but can lead to fatal infections. d. What causes decubitus ulcers?

Decubitus ulcers are caused by prolonged pressure on the skin preventing blood from reaching the tissues. An adequate supply of blood allows tissues to stay alive by providing nutrients and removing wastes. Certain conditions make decubitus ulcers more likely to develop; among these conditions are persons being unable to move normally, as in the case of stroke victims; being bed ridden due to old age, surgery, or accidents; and loosing sensation due to nerve damage or dementia (Jones, 2005). Individuals with nerve damage or dementia tend not to feel or notice their pain or discomfort. This lack of pain perception causes them to move less often and be more prone to pressure sores. Pressure applied for just two hours can damage the skin and result in a pressure sore (Jones, 2005). Other risk factors for pressure ulcers include bowel or bladder incontinence, malnourishment or significant weight loss, edema, anemia, hypoxia, or hypotension (Nettina, 2006).e. Where are decubitus ulcers most likely to occur?

Pressure sores are most common over any bony prominence. These locations are the occipital region, the ear, scapula, elbow, sacrum, ischial tuberosities, greater trochanter, medial condyle of tibia, fibular head, medial malleolus, lateral malleolus, and heel (Nettina, 2006). The areas are more susceptible if the layers of muscle and fat between the bone and skin are thin (Jones, 2005).f. Who is at most risk for decubitus ulcers?

Bedsores affect anyone who is unable to change positions for extended periods of time. The elderly, however, are especially susceptible due to their thin skin and weak circulation (Morris, 2004). In fact, about one fourth of all residents in nursing homes will develop pressure sores (Jones, 2005). As people age, epidermal replacement of cells slows and skin becomes thin, dry, and itchy, the subcutaneous fat layer diminishes, and there is decreased elasticity of the skin (Marieb & Hoehn, 2006). All of these developmental aspects contribute to the increased occurrence of bedsores in the elderly. Another group that is highly at risk for decubitus ulcers are people with spinal injuries. One in 12 people in America living with spinal cord injuries die from complications of pressure sores (http://www.mayoclinic.com/health/bedsores/DS00570). This is due to decreased sensitivity to pain perception and lack of movement causing pressure sores to advance quickly from stage I to stage IV.g. What environments are most likely to result in decubitus ulcers?

Anything that causes an injury to the integument system to heal more slowly can contribute to the development of a decubitus ulcer. Examples include malnutrition, diabetes, smoking, and poor circulation (Jones, 2005). Moisture against the skin can also add to the risk of decubitus ulcers because it can cause the skin to breakdown (Morris, 2004). This is especially true for individuals who cannot control their bowel movements or urination as it possibly could remain in contact with their skin for a period of time. h. What practices are most likely to result in decubitus ulcers?

Multiple practices can result in decubitus ulcers. For individuals who require assistance to move, friction and the shearing force from sliding the person can contribute to pressure ulcer development by causing abrasion of the stratum corneum (Nettina, 2006). Without the proper techniques for moving an individual, there is an increased likelihood of decubitus ulcer development. This is often the result of dragging a person across a bed causing damage to the skin or having the person slide to the edge of a bed or chair causing a shearing force between the coccyx and the overlying skin. Not moving an immobile person frequently can result in decubitus ulcer development, as well as improper hygiene and malnutrition.i. What other complications can result from decubitus ulcers?

Many complications can result from pressure ulcers which even the most conscientious care cannot prevent. The complications include: cellulitis, an infection of the skin's connective tissues; which can also lead to sepsis, bacteria from a massive infection enters your bloodstream and spreads throughout your entire body; or meningitis, an infection of the membrane and fluid surrounding your brain and spinal cord (http://www.mayoclinic.com/health/bedsores/DS00570). Other complications include bone and joint infection; necrotizing fasciitis, an infection that destroys layers of tissues that surround the muscles; or myonecrosis also called gas gangrene, a form of gangrene that develops suddenly and spreads so rapidly tissue changes are noticeable almost immediately (http://www.mayoclinic.com/health/bedsores/DS00570). j. What are the current practices to treat decubitus ulcers?

The treatment of decubitus ulcers depends greatly on the stage in which the ulcer is first diagnosed. Stage I and stage II bedsores require pressure relief of the affected area which simply involves changing the individual's position so the site can receive adequate circulation. The individual should not sit or lie on the affected area and it should be kept clean and dry. If the individual is undernourished, protein, calorie, vitamin C, and zinc supplements may help the affected tissue heal more quickly (Jones, 2005). In the advanced stages, the dead tissue should be removed with a scalpel or chemical solution (Jones, 2005). The wound should then be thoroughly cleaned and with a sterile solution and covered with a dressing to keep out bacteria until the wound can begin to heal. In some cases, a skin graft may be required to help prevent infections and speed the healing process (Jones, 2005). This can be a risk if the person is frail or malnourished, and should only be used in extreme cases. If all other treatments are ineffective, flap surgery may be required when an area of the skin next the affected site is cut and folded over the sore (Jones, 2005). This procedure is also extremely risky as there is a chance of extended tissue loss and therefore should only be used as a last resort. The most effective way to treat decubitus ulcers is to prevent them from the beginning by maintaining the skins integrity, promote healing, and keep a watchful eye for any pressure sore development.k. What anatomical systems are affected by decubitus ulcers?

Multiple anatomical systems are affected by decubitus ulcers depending on the stage of the ulcer. In all stages the integument system is affected as this is where the initial sore takes place. The lymphatic system will always be affected as well because it will be required to pick up fluid and remove any debris from the affected area and will mount and attack against any foreign bodies (Marieb & Hoehn, 2006). In stage III and IV the muscular system is affected as well. In stage IV the skeletal system will be affected and there is a possibility of many more systems being affected depending on how long the pressure ulcer is allowed to continue and by the complications it presents. If infection occurs, the cardiovascular system could be involved if the infection spreads throughout the body; at this point, all anatomical systems will be affected in one fashion or another.l. What senses are affected by decubitus ulcers?

Depending on the severity of the decubitus ulcer, all of the senses could be affected. It is more likely that the senses will be suppressed prior to the development of the decubitus ulcer rather than from the ulcer itself. For example, elderly individuals, (the group of people most likely to be affected by pressure sores) senses are already suppressed due to their age. The decubitus ulcer more than likely will not cause different sense loss, but may increase the suppression of the senses as the body fights back. For spinal cord injury victims, their sense of touch in certain regions of their body may be impaired. The decubitus ulcer did not cause this impairment; however, because of the loss of tissue, the affect may be increased. More than likely any individual's other senses will not be affected unless infection sets in, in which case the body could react in shutting down and therefore would sustain a loss of one or more of the senses. m. Summary

In conclusion, a decubitus ulcer is a pressure induced wound in the skin which is classified in stages depending on the severity. They are caused by a lack of blood supply to a region of the skin and are most likely to occur over bony prominences. Anyone unable to move normally is at risk for developing decubitus ulcers and any environment in which the integument system is slow to heal will increase the risk of decubitus ulcer development. An individual not moving frequently enough or being moved improperly is more likely to result in decubitus ulcers. Multiple complications may arise, which typically result from an infection in the affected tissue. The best treatment is prevention; however, realistically there is no way to prevent all pressure sores. Therefore, when one does develop the area should be kept clean, dry, and pressure-free.

References

Jones, T. V. (Ed.). (2005). The merck manual of health & aging: the comprehensive guide to the changes and challenges of aging- for older adults and those who care for and about them. New York: Ballantine Books.

Marieb, E. N. & Hoehn, K. (2006). Human anatomy & physiology, seventh edition. San Francisco: Pearson Benjamin Cummings.

Mayo Foundation for Medical Education and Research. (2005, March 18). Mayo Clinic. Bedsores: Pressure sores. Retrieved September 9, 2006, from http://www.mayoclinic.com/health/bedsores/DS00570

Morris, V. (2004). How to care for aging parents. New York: Workman Publishing Company, Inc.

Nettina, S. M. (2006). Lippincott manual of nursing practice, eighth edition. Philadelphia: Lippincott, Williams & Wilkins.

Pickett, J. (Ed.). (2002). The American heritage college dictionary. Boston: Houghton Mifflin Company.