Wound care refers to specific types of treatment for pressure sores , skin ulcers and other wounds that break the skin. Pressure ulcers, also called “bed sores” and referred to medically as decubitus ulcers, are wounds that commonly develop at pressure points on the body when the weight of an immobilized individual rests continuously on a hard surface such as a mattress or wheel chair. Uninterrupted pressure is the cause of pressure sores and relieving pressure is the mainstay of wound care. Other wounds that may benefit from specialized wound care techniques are diabetic foot ulcers, traumatic ulcers caused by injury, arterial and vein ulcers caused by lack of circulation, and burns.
The purpose of wound care is twofold: 1) to relieve pressure on a weight-bearing part of the body such as a boney prominence (hand, arm, knee, heel, hip or buttocks) that rests on a bed, wheelchair, another body part, a splint or other hard object, and 2) to treat the ulcerated wound itself when skin has become weakened, inflamed and possibly infected. Although the current discussion of wound care relates primarily to pressure ulcers, other skin ulcers and burn wounds may benefit from similar treatment principles and practices.
Pressure sores develop in immobilized individuals who are constantly positioned the same way in a bed, chair or wheelchair or who may be in traction or paralyzed with limited range of motion. Older individuals who are compromised through acute or chronic illness, under heavy sedation or unconscious, or who have reduced mental functioning, typically do not receive normal nerve signals to move as mobile individuals do. Tissue damage may begin as tender inflamed areas over weight-bearing parts of the body that are in contact with a supporting surface such as a bed or wheelchair, or with another body part or a supportive device. Constant contact at these points exerts pressure on the skin and soft tissue, cutting off the normal flow of blood, oxygen and nutrients to tissue (ischemia ), resulting in death of tissue cells
(anoxia ) and formation of pressure sores. The presence of sores is complicated by rubbing (shear) or friction between the supportive surface and skin over boney prominences. In compromised, immobilized individuals, skin breakdown can happen quickly within hours or days. Regular movement or turning of the individual is needed to relieve pressure, and clinical treatment of pressure sores is required to prevent infection and further breakdown.
Physicians orders are required for wound care designed to prevent and treat pressure sores. Alertness to skin condition in immobilized patients is critical among caretakers and medical personal. Individuals at risk for pressure sores may only be aware of discomfort at the points of pressure and may not be aware of the presence of sores or the risk of infection. Caretakers should be informed of pressure sore risk and instructed about typical signs and preventive measures to protect the skin of at-risk individuals in their care.
Steps of recovery
Wound care is usually ordered for any immobilized or bedridden individual with compromised skin integrity in order to prevent pressure sores from developing or to keep red, tender areas from deepening into serious wounds. Care is typically provided by specialized registered nurses called “enterostomal therapists” who are trained in skin and wound care as well as incontinence care and retraining, and care of individuals with surgically diverted urinary or fecal elimination (ostomy). A thorough risk assessment is conducted first and therapy is designed accordingly, employing specific wound care principles and practices shown to be effective for various levels of tissue injury.
Enterostomal therapists will note any conditions such as underlying disease, incontinence, or mental confusion that could impede pressure sore recovery. Nutritional status will be evaluated and a specific dietary plan may be designed to provide nutrition to benefit skin healing, including dietary supplements , intravenous (parenteral) feeding, restoring nitrogen balance and normal protein levels. Weight loss may be recommended for obese individuals. Pressure sores will be classified in one of four stages based on wound depth and skin condition: Stage I has intact skin with redness (erythema) and warmth; Stage II has loss of normal skin thickness, possible abrasion, swelling and blistering or peeling of skin; Stage III has full loss of normal skin thickness, an open wound (crater), and possible exposure of deeper layers of skin; Stage IV has full loss of normal skin thickness and erosion of underlying tissue extending into muscle, bone, tendon or joint, along with possible bone destruction, dislocation or pathologic fractures. Therapists will note if wounds are draining, if foul odors are present, or if any debris such as pieces of dead skin are in the wound. Presence of urine or feces from incontinence will be noted as well and regular care personnel will be advised about need for increased hygienic measures.
Reducing or eliminating pressure is the first task of wound care and requires the cooperation of the nursing center or family member responsible for onsite care. Recommendations will be made for shifting or turning the patient every two hours or other regular intervals. Some patients may benefit from lying flat on their backs; others may need the head of the bed lowered. Shear can be minimized by placing the patient on a special surface that alternates pressure points. A low-level of pressure relief can be obtained by using egg-crate mattresses or chair cushions. Egg-crate surfaces are constructed of sculpted foam with deep gullies between raised points of cushioning, which alternates pressure on vulnerable areas. Other types of air, foam and gel pressure-relieving surfaces are available. Wheel chair patients may need to be trained to shift their weight or lean side to side to relieve pressure. For deep wounds, burns, or pressure sore prevention, special “low air-loss” or “air-fluidized” beds are available that relieve pressure by constantly-moving air within specially designed pillows or within an entire bed surface filled with millions of tiny silicone-coated beads. Many institutions use beds that employ these principles to help heal wounds of all types and to prevent pressure sores from developing in at risk individuals.
Wound Cleansing and Dressing
For more superficial Stage I and II pressure sores, treatment will involve keeping the wound clean and moist, and the area around the sore clean and dry. Saline washes may be used and placement of sterile medicated non-stick gauze dressings that absorb wound drainage and fight infection-causing bacteria. Other bio-protective cleaning solutions include acetic acid, povidone iodine, and sodium hypochlorite. Harsh antiseptics, soaps and regular skin cleansers are not used because they can damage newly developing tissue. However, drying agents, lotions or ointments may be applied in a thin film over the wound three or four times daily. Massage of any at-risk area should be avoided because it encourages skin breakdown.
Warm-water whirlpool treatments are sometimes used to treat pressure ulcers on arms, hands, feet or legs. This technique removes destroyed tissue fragments (necrotic tissue) by the force of irrigation followed by application of wet-to-dry non-stick dressings. After a wet dressing has been applied to the wound and allowed to dry, its removal picks up necrotic debris and a new dressing of sterile, medicated non-stick gauze or semi-permeable transparent adhesive dressings is applied to keep the area dry and prevent destruction of healthy skin near the wound, reducing risk of infection. Adhesive dressings are not recommended for draining wounds.
Hyperbaric Oxygen Therapy
Treatment of Stage III and IV decubitus ulcers, and other types of skin ulcers or burn wounds, may benefit from treatment that saturates the body with oxygen. The individual rests in a pressurized hyperbaric oxygen chamber, breathing 100% oxygen for 90 to 120 minutes. As the oxygen is absorbed by the blood, extra oxygen is provided to all cells and tissues, increasing healing capability and clearing of bacterial infection. Hyperbaric chambers are available in larger hospitals and medical centers.
Antimicrobial or Antibiotic Therapy
Antimicrobial topical therapy or oral antibiotic therapy may be recommended by the individual's physician to prevent possible bacterial infection or to address existing infection. Silver sulfadiazine is applied topically with good results. Antibiotics taken orally include penicillins, cephalospoins, aminoglycosides , sulfonamides, metronidazol and trimethoprim. Selection is based on specific bacteria causing infection or on obtaining the broadest possible coverage. Tissue biopsy may be performed to identify the causative bacteria.
Debridement and Debriding Agents
Surgical treatment is often needed for wounds showing poor response to standard wound care. Debridement is a surgical procedure that uses either a scalpel or chemicals to remove dead tissue (necrotic debris) from Stage III and IV wounds. Enzymatic debridement uses proteolytic enzymes that destroy collagen and necrotic wound debris without damaging new tissue. Mechanical debridement or “sharp debridement” perfomed with a scalpel loosens the necrotic tissue and removes it to encourage growth of new tissue. Debridement is accompanied by blood loss and may not be possible in individuals who are anemic or cannot afford to lose blood.
Urinary or Fecal Diversion
Incontinent individuals may require a surgical procedure (urinary or fecal diversion) to redirect the flow of urinary or fecal material to keep the wound clean, reducing likelihood of infection and encouraging positive response to medical treatment.
Stage III and IV wounds may require consultation with a plastic surgeon to evaluate benefits of reconstructive surgery. Reconstructive surgery involves completely removing the ulcerated area and surrounding tissue (excision), debriding the bone, flushing the area with saline (lavage) to remove excess bacteria, and placing a drain in the wound for several days until risk of infection is gone and evidence of healing becomes apparent. Smaller wounds may then be sutured closed. Plastic surgery may follow surgical excision of a larger wound area, placing a flap of skin from another part of the body over the area to provide a new tissue surface. Skin grafts and other types of flaps may also be used for surgical closure (secondary closure) of excised wounds.
Healing existing pressure sores and preventing recurrence is a long, arduous task for wound care professionals and caretakers, requiring patience and constant care. Impaired mobility is the critical factor in developing pressure sores, but risk in immobilized or bedridden individuals is increased by acute or chronic illnesses or conditions that might weaken muscles or soft tissue or that reduce blood circulation, which robs tissues of needed oxygen and causes skin to be thinner and more likely to break down and become infected. Conditions in immobilized older adults that may compromise skin integrity, increase risk of pressure sore development, or impede healing of pressure sores, include:
- atheroslerosis or peripheral vascular disease
- heart disease
- incontinence, inability to control urination or bowel movements
- stroke, paralysis (paraplegia) or spinal cord injury
- sensory loss (as in paralysis) with diminished sense of pain
- chronic infection
- smoking tobacco, which compromises skin healing
When therapists are providing regular care for individuals with existing pressure ulcers or at risk for pressure sores, progress may be challenged if caretakers are not able to identify warning signs of skin breakdown on regular inspection, are not providing regular bathing or care for incontinence, or are not consistent in moving patients as needed to support ongoing treatment. Adequate instruction must be provided to caretakers by therapists and consistent care given to the individual in order to achieve good results.
Risk is high for recurrence of pressure sores and deepening of existing sores into serious infection, especially in individuals compromised by poor nutritional status, chronic disease, or reduced immune system function. Complications can occur after pressure sore surgery, including bleeding under the skin (hematoma), bacterial infection, and wound recurrence. Amputation may be required if wounds will not heal or reconstructive surgery is not an option due to poor overall health status. Infection in deep wounds can spread to the blood and the entire body, becoming life threatening. Individuals at high risk for pressure ulcers are also at higher risk for chronic infection and death.
Anoxia —Reduced or almost entire absence of oxygen in the blood, cells and tissues of the body resulting in tissue death.
Debridement —Cutting away or “excising” dead tissue from a wound.
Erythema —Redness and warmth of the skin caused by dilation of small blood vessels (capillaries) under the skin.
Excision —Removal of tissue, organ, limb or other body part by cutting.
Friction —A force exerted when two surfaces move across each other such as moving patients across a bed or other support surface.
Hematoma —An area of blood that has gathered and remains confined under the skin or within an organ or body tissue.
Ischemia —Localized anemia stemming from reduced flow of blood and oxygen to organs and tissue, including skin.
Pathologic fracture —A fracture that occurs spontaneously at a weakened area of bone.
Shear —Mechanical stress experienced at the plane of the affected area such as pressure sores on the lower back or hip.
Ulcer —An inflammed sore or “lesion” that occurs on a surface such as skin or the mucus membrane of an organ, typically breaking the skin or membrane and resulting in loss of tissue.
When consistent care is provided including removal or reduction of pressure source, attention to the patient's general health and underlying condition, and treatment of existing wounds, pressure sores typically heal between two and four weeks after starting treatment. For successful surgical results, infection and complications must be avoided. Preventing recurrence of pressure sores requires regular surveillance and avoidance of pressure on vulnerable areas.
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Haggerty M, Culvert LL. “Bedsores.” Gale Encyclopedia of Surgery. Farmington Hills, MI: Gale/Thomson; 2000.
Salcido R, Popescu A. “Pressure Ulcers and Wound Care.” eMedicine Specialties. The Medscape Journal. Available at www.emedicine.com/pmr/topic179.htm. Updated Aug. 10, 2006. Accessed March 17, 2008.
Revis DR. “Decubitus Ulcers.” eMedicine Continuing Education, Available at emedicine.com. Updated August 2003. Accessed March 17, 2008.
National Pressure Ulcer Advisory Panel, 12100 Sunset Hills Road, Suite 130, Reston, VA, 20190, 703-464-4849, 703-435-4390, [email protected], International Association of Enterostomal Therapists, 27241 La Paz Road, Suite 121, Laguna Niguel, CA, 714-476-0268.
L. Lee Culvert