A time comes for many elderly people to get bedridden or confined to a wheelchair due to certain health issues. As a family member or a caregiver, one must be very vigilant about the skin parts that always come in contact with a surface, which can result in sore skin. Your parents or grandparents may not be in a position to express or communicate their discomfort. Discovering any such signs of skin sores at an early stage will help in preventing further damage to the skin, and bring some amount of comfort to your loved ones.
Describing pressure sores
These develop as a result of constant pressure on a particular area of the body, which reduces the blood supply to the skin, leading to death of the underlying tissue. By remaining in one position for too long, such pressure sores can develop quickly, and progress to a condition when it becomes difficult to heal. Areas more prone are where the bone is in close contact with the skin such as ankle, back, elbow, heels, and hips. Lying in a bed or sitting in a wheelchair without changing the body position frequently can develop bedsores, also known as decubitus ulcers or pressure ulcers.
Risk factors
Anybody who gets immobilized as a result of severe illness or injury can develop pressure sores, but more so in elderly people who tend to have thinner skin and decreased blood circulation due to aging. The following factors increase the risk of getting pressure ulcers:
- Nursing home residents, who might not be getting enough quality care and attention.
- Being older than 70 years, makes the skin fragile and susceptible to damage from even minor pressure.
- Weight loss due to sickness or hospitalization
- Poor diet, especially deficient in protein, zinc and vitamin C
- Urinary or fecal incontinence, which causes the skin to remain moist and get infected.
- Medical conditions like diabetes, or vascular diseases that affect blood circulation, increases the risk of tissue damage.
- Decreased awareness in cases of mental disabilities or due to medications, resulting in improper care for the skin.
- Inability to move certain body parts due to paralysis or neuromuscular diseases.
Overall, pressure (on skin over bony areas), traction (skin gets stretched), friction (repeated pulling across a surface), moisture (skin in contact with urine, feces or sweat), and inadequate nutrition contribute towards greater risk in formation of bedsores.
Stages of severity
Depending on the extent of tissue damage, there are four stages of severity:
Stage 1: There is a persistent area of redness (maybe blue or purple in darker skins), with a change in skin temperature, consistence and sensation. The area maybe warm to touch, and may hurt, itch or burn.
Stage 2: Here, there is partial skin loss and the ulcer looks like an abrasion, blister or shallow crater. The epidermis, dermis or both can be affected, showing red or purple discoloration and is quite painful.
Stage 3: Full thickness skin loss occurs, causing damage to the tissue below the skin, making a crater like appearance. The wound is deeper, with blackish edges.
Stage 4: With heavy skin loss, there is extensive tissue death, damage to muscle, bone or supporting structures (joints or tendons). The wound is very large and is prone to infection. This stage is the most serious and advanced.
Treatment and management
Stages 1 and 2 bedsores need several weeks to heal with conservative treatment, while stages 3 and 4 might need surgery and are less likely to resolve by themselves. In conservative treatment, the pressure causing the sore must be relieved by changing the patient’s position often; in a wheelchair every 15 minutes and if in bed, once in two hours. While moving, friction must be avoided between the wound and any surface, so provide some padding or covering. There are also support surfaces available, like special cushions, pads, mattresses and beds that bring relief to existing sores and prevent further tissue damage.
Specialty beds like air-fluidized beds (made of silcone-coated beads pumped with air) are recommended for patients with multiple large pressure sores, while low-air-loss beds have air-filled pillows, the pressure of which can be altered as per the patient’s requirement. A combination of air-fluidized and low-air-loss beds are also available. These beds provide pressure relief and reduce friction and moisture from accumulating. However, donut or ring shaped cushions are not recommended as these interfere with blood flow, causing complications.
Cleaning the wounds to prevent infection is very essential. Many types of dressings are available to protect the sores and speed up healing, depending on the stage of the wound. It is important to keep the wound moist, but the surrounding skin dry. Sores at stage 1 can be washed using water and a mild soap, and need not be covered. Stage 2 sores need semi-permeable dressings to retain moisture and encourage skin cell growth, and need to be cleansed with saline solution. Debridement or removal of damaged tissue can also be done by a doctor:
- Mechanical debridement: using an irrigation device
- Autolytic debridement: body’s own enzymes breaks down dead tissue
- Enzymatic debridement: application of topical enzymes for removing dead tissue.
Hydrotherapy in the form of whirlpool baths can help remove contaminated tissue and clean the wound. Having a nutritious diet rich in vitamins and minerals, especially vitamin C and zinc can help in wound healing.
In a surgical procedure, a pad of muscle, skin or other tissue taken from the patient’s own body is used to cover the wound (flap reconstruction) after extensive debridement. The goal here is to improve hygiene and appearance of the sore, as well as preventing or treating infection.
Complications
Despite care and a hygienic approach, infection can set in due to an open sore, which should be controlled by medical intervention. Signs of infection include:
- Foul odor from the ulcer
- Redness or tenderness surrounding it
- Thick yellow or green pus
The infection might have spread throughout the body if there is fever, chills, confusion, weakness or rapid heartbeats. It needs to be ascertained if complications such as cellulitis (acute infection of the skin’s connective tissue), bone and joint infection (infectious arthritis, osteomyelitis), sepsis (bacteria entering the bloodstream) and cancer of the skin have set in, most of which are life threatening. Depending on the extent of infection, treatment with antibiotics either locally at the site or intravenously maybe carried out.
Prevention
Pressure sores are definitely preventable, if extra care is taken by the caregiver or family member to ensure that no part of the body is exposed to prolonged pressure. The skin should be kept clean and dry, and always observed for color changes or spots, with special attention to the areas more prone. People who cannot move themselves have to be repositioned every 2 hours, and the sheets should be kept clean and dry. Appropriate seat cushions, beds or mattresses must be used for wheelchair-bound or bedridden individuals. Lying down directly on the hipbone must be avoided, and proper support must be given to the legs. With the help of a physical therapist, doing certain exercises can help improve blood flow.
Conclusion
If you have a loved one in a nursing home, hospital or any other care facility, do make it a point to check their skin condition on every visit. The sooner you alert a nurse or physician of a suspected sore, the easier it will be to manage the condition. The least we can do for the elders who have looked after us, is to keep a watchful eye, making sure that they are comfortable and happy.
