In our last article, we looked at some alarming U.S. statistics regarding deficiencies noted in the care of residents in a nursing home environment. While there are many issues that can arise involving unsatisfactory patient care, one that is becoming increasingly prevalent is the development of pressure sores on patients.

In this article, we are going to spend some time providing a brief overview of pressure sores.  This discussion will include some of the symptoms that can be monitored to prevent this very serious health condition as well as treatment regimens based on the severity of the sore.

“Pressure sore” is the term that most accurately describes this condition. Other names that are commonly referred to in describing this injury are bed sores, pressure ulcers, or decubitus ulcers. A bed sore is a painful injury to the skin and underlying tissues. It is a process of degeneration and breaking-down of the affected area caused by pressure and lack of movement, which then cuts off circulation to the affected area. The area is often worsened by urine and other irritating substances that come in contact with the skin. Pressure sores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips, or buttocks.  To prevent pressure sores, these areas should be especially monitored.

Patients most at risk for bedsores are those with a medical condition that limits their ability to change positions, e.g., prolonged use a wheelchair or being confined to a bed for extended periods of time. These wounds often develop quickly and can be difficult to treat. Malnutrition, when combined with other risk factors, may also lead to a pressure ulcer in a person who otherwise would not have developed one. Poor nutrition results in deterioration of overall body functioning, and as the largest organ of the body, one's skin is usually the first place where the consequences of inadequate nutrition may be visible.

As with many health conditions, bed sores are easier to prevent than treat. The most effective way to prevent these sores from developing is frequent repositioning. Repositioning should occur at least every two hours. Special mattresses and proper support surfaces should also be made available in an effort to relieve pressure and friction from boney prominences and protect them from damage. These include foam or air filled mattresses, positioning aides and supportive devices such as heel protectors, and wheelchair cushions or inserts for prolonged sitting. When your loved one is in a nursing home environment, and their general health condition begins to decline preventing their ease of mobility, you should communicate with the health care professionals at the nursing home to ensure that your loved one has access not only to a special mattress or support surface, but also that your loved one's health care regimen includes scheduled repositioning and frequent assessments of their skin integrity.

In addition to having the proper support surface, other necessary preventative care measures include proper skin care, regular skin inspections, and good nutrition and hydration. These are all factors that help to avoid this dangerous and potentially incurable health condition.

The National Pressure Ulcer Advisory Panel, a professional organization that promotes the prevention and treatment of pressure ulcers, has defined four stages that rank the severity of pressure sores.  The figure below is helpful in this explanation.

Stage I : This is the beginning stage of a pressure sore and has the following characteristics:

• Stage II: The stage II ulcer is an open wound:
• The site may be painful, firm, soft, and warmer or cooler compared with surrounding skin.
• On people with darker skin. There may be no change in the color of the skin, and the skin doesn't blanch when touched. Or the skin may appear ashen, bluish, or purple.
• The skin appears red on people with lighter skin color, and doesn't lighten (blanch) when touched, also this red area does not subside after 30 minutes.
• The skin is intact.
• It may also appear as an intact or ruptured fluid-filled blister.Stage III: At this stage, the ulcer is a deep wound:
• The pressure ulcer may appear as a shallow, pinkish-red, basin-like wound.
• The outer layer of skin and part of the underlying layer of skin is damaged or lost.
• The loss of skin usually exposes some amount of underlying fat tissue.
• The ulcer has a crater-like appearance.
• The bottom of the wound may have some yellowish dead tissue called slough.
• The damage may extend beyond the primary wound below layers of healthy skin. This is called tunneling.Stage IV: The stage IV ulcer exhibits large-scale loss of tissue:
• The wound may expose muscle, bone, and tendons.
• The bottom of the wound likely contains slough or dark, crusty dead tissue called eschar.
• The damage often extends beyond the primary wound below layers of healthy skin.

Often there is no feeling to the deep areas of these wounds because nerve damage has been done at this point.You should contact your loved ones doctor right away if you notice any signs or symptoms of a pressure ulcer developing. Getting prompt and immediate medical care is critical to prevent the advancement of this condition. If the sore is discovered during Stages I or II, these injuries can heal within weeks to months with conservative care to the wound and ongoing interventions to relieve the pressure and skin irritants. It is also important to have a nutritional evaluation. Supplemental nutrition that provides balanced amounts of protein, energy, vitamins and minerals can help provide the nutrients the body needs for healing that are often diminished or missing in elderly patients.If a pressure sore is allowed to develop to Stage III or IV, they become much more difficult to treat.

Often times a person with these type pressure sores is one that has some terminal illness or multiple chronic medical conditions, which further complicates the treatment of the pressure sores, and health care professionals may focus on managing pain, rather than the complete healing of the wound. However, untreated bedsores can become seriously infected or gangrenous, leading to further complications, both locally and throughout the body.Prompt medical attention and intervention is needed to stop the wound's progression.  Once discovered, general treatment protocol requires insuring that pressure is relieved from the affected site. If the skin remains intact, never compromise this by breaking the skin, such as popping a blister mentioned in Stage II above. In advanced wounds, dead tissues must be removed from the wound bed to promote healing and prevent infection. This is sometimes done chemically, but often requires surgical intervention. Keeping the wound properly cleaned and dressed is important, while protecting the healthy skin surrounding the wound with proper protectant and skin barrier.

Finally the patient should be given a careful pain management regiment to alleviate any pain, and increase their quality of life. Antibiotics are sometimes required if the pressure sore has become infected. Even with appropriate and preventative care, pressure wounds may still develop. Nursing home facilities have guidelines and regulations that have been established to gauge whether proper care and treatment is being provided. The Nursing Home Quality Initiative highlights the use of a Minimum Data Set, MDS 3.0, which is an assessment performed by a Registered Nurse, to help facilities recognize a resident's individual risk factors and provide appropriate care planning and intervention. This information is also entered on each resident, then collected by state and federal regulators for Quality Indicator monitoring of each facility.If your loved one is beginning to experience the first stages of pressure sore development or has already developed an advanced wound, immediate medical attention is required and you should insure to your satisfaction that the nursing facility is taking the proper precautions and have initiated appropriate interventions. 

The references listed below provide additional helpful information regarding the overview and treatment of pressure sores. Your being equipped with the knowledge of how and why pressure sores develop will enable you to be an effective advocate for your loved one in a nursing home or assisted living type environment.

References:

1. http://www.nlm.nih.gov/medlineplus/pressuresores.html
2. http://dying.about.com/od/caregiving/f/PU_early_stage.htm
3. http://assistedliving.about.com/od/nursinghomes/a/Mds-3-0-Skin-Conditions.htm
4. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/index.html?redirect=/NursingHomeQualityInits/25_NHQIMDS30.asp
5. http://www.mayoclinic.com/print/bedsores/DS00570/DSECTION=all&METHOD=print
6. http://www.webmd.com/skin-problems-and-treatments/tc/pressure-sores-topic-overview