Bedsores, more properly known as pressure ulcers or decubitus ulcers, are lesions caused by many factors such as: unrelieved pressure; friction; humidity; shearing forces; temperature; age; continence and medication; to any part of the body, especially portions over bony or cartilaginous areas such as sacrum, elbows, knees, ankles etc. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings L00-L99 - Diseases of the Skin and Subcutaneous tissue (L00-L08 Infections of the Skin and Subcutaneous tissue The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books A lesion is any abnormal tissue found on or in an organism usually damaged by disease or trauma Pressure (symbol 'p' is the force per unit Area applied to an object in a direction perpendicular to the surface Bones are rigid organs that form part of the Endoskeleton of Vertebrates They function to move support and protect the various organs of the body produce Cartilage is a type of dense Connective tissue. It is composed of specialized cells called chondrocytes that produce a large amount of extracellular matrix Although completely treatable if found early, without medical attention, bedsores can become life-threatening, and indeed fatal.

Classification

The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP) in the United States. Briefly, however, they are as follows:

• Stage I is the most superficial, indicated by non blanchable redness that does not subside after pressure is relieved. This stage is visually similar to reactive hyperemia (a technical term for excessive redness) seen in skin after prolonged application of pressure. Stage I pressure ulcers can be distinguished from reactive hyperemia in two ways: a) reactive hyperemia resolves itself within 3/4 of the time pressure was applied, and b) reactive hyperemia blanches when pressure is applied, whereas a Stage I pressure ulcer does not. The skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient. Although easy to identify on a light-skinned patient, ulcers on darker-skinned individuals may show up as shades of purple or blue in comparison to lighter skin tones.
• Stage II is damage to the epidermis extending into, but no deeper than, the dermis. Epidermis is the outermost layer of the Skin. It forms the waterproof protective wrap over the body's surface and is made up of stratified squamous Epithelium with The dermis is a layer of Skin beneath the epidermis that consists of Connective tissue, and cushions the body from stress and strain In this stage, the ulcer may be referred to as a blister or abrasion. A blister is a small pocket of fluid within the upper layers of the skin
• Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer. The subcutaneous tissue or subcutis is the layer of Loose connective tissue directly underlying the Dermis. This layer has a relatively poor blood supply and can be difficult to heal. At this stage, there may be undermining damage that makes the wound much larger than it may seem on the surface.
  

  Stage IV pressure ulcer
• Stage IV is the deepest, extending into the muscle, tendon or even bone. Muscle (from Latin musculus, diminutive of mus "mouse" is contractile tissue of the body and is derived from the A tendon (or sinew) is a tough band of Fibrous connective tissue that usually connects Muscle to Bone and is capable of withstanding tension Bones are rigid organs that form part of the Endoskeleton of Vertebrates They function to move support and protect the various organs of the body produce
• Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined. From the Greek word eschara (scab an eschar (ˈɛskɑr is a piece of dead tissue that is cast off from the surface of the skin particularly after a burn injury

With higher stages, healing time is prolonged. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year. ^[1] It is important to note that pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e. g. , healing Stage II pressure ulcer).

Etiology

Bedsores are accepted to be caused by three different tissue forces:

Pressure, or the compression of tissues. In most cases, this compression is caused by the force of bone against a surface, as when a patient remains in a single decubitus position for a lengthy period. Commonly used in medicine the word decubitus is used to mean "lying down" After an extended amount of time with decreased tissue perfusion, ischemia occurs and can lead to tissue necrosis if left untreated in an immunocompromised patient. In Physiology, perfusion is the process of nutritive delivery of Arterial Blood to a Capillary bed in the Biological tissue. In Medicine, ischemia ( Greek ισχαιμία, isch- is restriction hema or haema is Blood) is a restriction Necrosis (in Greek Νεκρός = "dead" is the name given to unnatural Death of cells and living tissue. In Medicine, immunodeficiency (or immune deficiency) is a state in which the Immune system 's ability to fight Infectious disease is compromised

Shear force, or a force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity. Fascia (făsh'ē-ə pl fas·ci·ae (făsh'ē-ē adj fascial (făsh'ē-əl (from Latin: a band is the Soft tissue component of Skeletal muscle is a type of Striated muscle, which usually attaches to tendons This can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis. The blood vessels are part of the Circulatory system and function to transport Blood throughout the body In Medicine, ischemia ( Greek ισχαιμία, isch- is restriction hema or haema is Blood) is a restriction Necrosis (in Greek Νεκρός = "dead" is the name given to unnatural Death of cells and living tissue.

Friction, or a force resisting the shearing of skin. This may cause excess shedding through layers of epidermis. Epidermis is the outermost layer of the Skin. It forms the waterproof protective wrap over the body's surface and is made up of stratified squamous Epithelium with

Aggravating the situation may be other conditions such as excess moisture from incontinence, perspiration or exudate. Urinary incontinence ( UI) is any involuntary leakage of Urine. An exudate is any Fluid that filters from the Circulatory system into Lesions or areas of Inflammation. Over time, this excess moisture may cause the bonds between epithelial cells to weaken thus resulting in the maceration of the epidermis. Other factors in the development of bedsores include age, nutrition, vascular disease, diabetes mellitus, and smoking, amongst others. Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Tobacco Smoking is the inhalation of smoke from burned dried or cured leaves of the Tobacco plant most often in the form of a Cigarette.

There are currently two major theories about the development of pressure ulcers. The first and most accepted is the deep tissue injury theory which claims that the ulcers begin at the deepest level, around the bone, and move outward until they reach the epidermis. The second, less popular theory is the top-to-bottom model which says that skin first begins to deteriorate at the surface and then proceeds inward. ^[2]

Stage 4 decubitus displaying the Tuberosity of the ischium protruding through the tissue and possible onset of Osteomyelitis

Pathophysiology

Pressure ulcers may be caused by inadequate blood supply and resulting reperfusion injury when blood re-enters tissue. Posteriorly the superior ramus of the Ischium forms a large swelling the tuberosity of the ischium (or ischial tuberosity) Osteomyelitis is an Infection of Bone or Bone marrow, usually caused by Pyogenic Bacteria or Mycobacteria. Reperfusion injury refers to damage to tissue caused when Blood supply returns to the tissue after a period of Ischemia. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas. Blood is a specialized Bodily fluid that delivers necessary substances to the body's cells ��such as nutrients and oxygen—and transports Waste products Within hours, this shortage of blood supply, called ischemia, may lead to tissue damage and cell death. In Medicine, ischemia ( Greek ισχαιμία, isch- is restriction hema or haema is Blood) is a restriction Tissue is a cellular organizational level intermediate between cells and a complete organism The cell is the structural and functional unit of all known living Organisms It is the smallest unit of an organism that is classified as living and is often called Death is the termination of the biological functions that define living Organisms It refers both to a specific The sore will initially start as a red, painful area, which eventually turns purple. Left untreated, the skin may break open and become infected. An infection is the detrimental Colonization of a host Organism by a foreign Species. Moist skin is more sensitive to tissue ischemia and necrosis and is also more likely to get infected. Necrosis (in Greek Νεκρός = "dead" is the name given to unnatural Death of cells and living tissue.

Epidemiology

Within acute care, the incidence of bedsores is 0. Incidence is a measure of the risk of developing some new condition within a specified period of time 4% to 38%; within long-term care, 2. 2% to 23. 9%; and in home care, 0% to 17%. There is the same wide variation in prevalence: 10% to 18% in acute care, 2. In Epidemiology, the prevalence of a Disease in a Statistical population is defined as the total number of cases of the disease in the population at a given 3% to 28% in long-term care, and 0% to 29% in home care. There is a much higher rate of bedsores in intensive care units because of immunocompromised individuals, with 8% to 40% of ICU patients developing bedsores. Intensive Care Medicine or critical care medicine is a branch of medicine concerned with the provision of Life support or organ support systems in patients ^[3]

The risk of developing bedsores can be determined by using the Braden Scale for Predicting Pressure Ulcer Risk. This scale is divided into six risk categories:

1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction and shear

The best possible interpretation is a score of 23 whilst the worst is a 6. If the total score is below 11, the patient is at risk for developing bedsores. ^[4]

Treatment

The most important thing to keep in mind about the treatment of bedsores is that the most optimal outcomes find their roots in a multidisciplinary approach; by using a team of specialists, there is a better chance that all bases will be covered in treatment.

There are six major contributors to healing.

Debridement

The removal of necrotic tissue is an absolute must in the treatment of pressure sores. Necrosis (in Greek Νεκρός = "dead" is the name given to unnatural Death of cells and living tissue. Because dead tissue is an ideal area for bacteria growth, it has the ability to greatly compromise wound healing. There are at least seven ways to excise necrotic tissue. ^[5]

1. Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes. In biology autolysis may refer to the destruction of a cell through the action of its own Enzymes It may also refer to the digestion of an enzyme by another molecule It is a slow process, but mostly painless.
2. Biological debridement, or maggot debridement therapy, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria. Maggot therapy (also known as maggot debridement therapy (MDT larval therapy larva therapy larvae therapy biodebridement or biosurgery is a type of Biotherapy involving Although this fell out of favour for many years, in January 2004, the FDA approved maggots as a live medical device. ^[6]
3. Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue.
4. Mechanical debridement is the use of outside force to remove dead tissue. A quite painful method, this involves the packing of a wound with wet dressings that are allowed to dry and then are removed. This is also unpopular because it has the ability to remove healthy tissue in addition to dead tissue. Lastly, with Stage IV ulcers, there is the chance that overdrying of the dressings can lead to bone fractures and ligament snaps.
5. Sharp debridement is the removal of necrotic tissue with a scalpel or similar instrument.
6. Surgical debridement is the most popular method, as it allows a surgeon to quickly remove dead tissue with little pain to the patient.
7. Ultrasound-assisted wound therapy is the use of ultrasound waves to separate necrotic and healthy tissue.

Infection control

Infection has one of the greatest effects on the healing of a wound. Purulent discharge provides a breeding ground for excess bacteria, a problem especially in the immunocompromised patient. Symptoms of systemic infection include fever, pain, erythema, oedema, and warmth of the area, not to mention purulent discharge. Fever (also known as pyrexia, from the Greek pyretos meaning fire or a febrile response, from the Latin word Febris Pain, in the sense of physical pain, is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm Erythema is redness of the Skin caused by Capillary congestion Oedema (or Edema in American English formerly known as dropsy or hydropsy, is the increase of Interstitial fluid in any organ &mdash swelling Pus is a whitish-yellow yellow or yellow-brown substance produced during Inflammatory responses of the body that can be found in regions of Pyogenic bacterial Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus.

In order to eliminate this bioburden, it is imperative to apply antiseptics and antimicrobials at once. Antiseptics (from Greek αντί - anti, '"against" + σηπτικός - septikos, "putrefactive" are antimicrobial It is not recommended to use hydrogen peroxide for this task as it is difficult to balance the toxicity of the wound with this. Hydrogen peroxide (H2O2 is a very pale blue liquid which appears colorless in a dilute solution slightly more Viscous than water New dressings have been developed that have cadexomer iodine and silver in them, and they are used to treat bad infections. Duoderm can be used on smaller wounds to both provide comfort and protect them from outside air and infections. Duoderm is an opaque dressing used in Medicine to protect Wounds from Contamination, and provide a moist wound-healing environment

It is not recommended to use systemic antibiotics to treat infection of a bedsore, as it can lead to bacterial resistance.

Nutritional support

Upon admission, the patient should have a consultation with a dietitian to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. A dietitian (also 'dietician' though 'dietitian' is used consistently by professionals is an expert in Food and Nutrition. The dietitian should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check serum albumin and lymphocyte counts. Serum albumin, often referred to simply as albumin, is the most abundant Plasma protein in humans and other Mammals Albumin is essential for maintaining A lymphocyte is a type of White blood cell in the Vertebrate Immune system. Additionally, a bioelectrical impedance analysis should be considered. Bioelectrical impedance analysis (BIA is a commonly used method for estimating body composition

If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with dietary supplements and nutrients including, but not limited to, arginine, glutamine, vitamin A, vitamin B complex, vitamin E, vitamin C, magnesium, manganese, selenium and zinc. Arginine (abbreviated as Arg or R) is an α- Amino acid. The L-form is one of the 20 most common natural amino acids Glutamine (abbreviated as Gln or Q; the abbreviation Glx or Z represents either glutamate or Glutamic acid) is one of the 20 Vitamin A refers to a family of similarly shaped molecules the Retinoids. The B vitamins are eight water-soluble Vitamins that play important roles in cell Metabolism. See also Tocopherol, Tocotrienol Vitamin E is the collective name for a set of 8 related Tocopherols and Tocotrienols which are fat-soluble Vitamin C or L-ascorbate is an Essential nutrient for a large number of higher primate species a small number of other Mammalian Magnesium (mægˈniːziəm is a Chemical element with the symbol Mg, Atomic number 12 Atomic weight 24 Manganese (ˈmæŋgəniːz is a Chemical element, designated by the symbol Mn. Selenium (səˈliniəm is a Chemical element with the Atomic number 34 represented by the chemical symbol Se, an atomic mass of 78 Zinc (ˈzɪŋk from Zink is a Metallic Chemical element with the symbol Zn and Atomic number 30 It is very important that intake of these vitamins and minerals be overseen by a physician, as many of them can be detrimental in incorrect dosages. A physician, medical practitioner or medical doctor who practices Medicine, and is concerned with maintaining or restoring human Health

Proper care

The most important care for a patient with bedsores is the relief of pressure. Once a bedsore is found, pressure should immediately be lifted from the area and the patient turned at least every two hours to avoid aggravating the wound. Nursing homes and hospitals usually set programs to avoid the development of bedsores in bedridden patients such as using a standing frame to reduce pressure and ensuring dry sheets by using catheters or impermeable dressings. SNF redirects here For the sports show see NBC Sunday Night Football. A hospital is an institution for Health care providing treatment by specialised staff and equipment and often but not always providing for A standing frame (also known as a stand, stander, standing technology, standing aid, standing device, standing box, In Medicine a catheter is a tube that can be inserted into a body cavity duct or vessel For individuals with paralysis, pressure shifting on a regular basis and using a cushion featuring pressure relief components can help prevent pressure wounds. Paralysed redirects here For other uses see xx Paralysed (disambiguation Paralysis is the complete loss of Muscle function

Pressure-distributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. However, methods to evaluate the efficacy of these products have only been developed in recent years. ^[7]

Educating the caregiver

In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one's pressure ulcers. The cross-specialisation wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things.

As this is a very difficult undertaking, the caregiver may feel overburdened and depressed, so it may be best to bring in a psychological consult.

Wound intervention

Once the patient has reached the point that intervention is possible, there are many different options. For patients with Stages I and II ulcers, the wound care team should use guidelines established by the American Medical Directors Association (AMDA) for the treatment of these low-grade sores.

For those with Stage III or IV ulcers, most interventions will likely include surgery such as a tissue flap, skin graft or other closure methods. Skin grafting is a type of Medical grafting involving the transplantation of Skin. A more recent intervention is Negative Pressure Wound Therapy, which is the application of topical negative pressure to the wound. Negative Pressure Wound Therapy (NPWT is the use of sub-atmospheric pressure to promote or assist wound healing or to remove fluids from a wound site This technique, developed by scientists at Wake Forest University, uses foam placed into the wound cavity which is then covered in a film which creates an airtight seal. Wake Forest University is a private, coeducational University in North Carolina, founded in 1834 Once this seal is established, the technician is able to remove exudate and other infectious materials in addition to aiding the body produce granulation tissue, the best bed for the creation of new skin.

There are, unfortunately, contraindications to the use of negative pressure therapy. In Medicine, a contraindication (pronounced as contra-indication is a condition or factor that increases the Risks involved in using a particular drug, Most deal with the unprepared patient, one who has not gone through the previous steps toward recovery, but there are also wound characteristics that bar a patient from participating: a wound with inadequate circulation, a raw debridled wound, a wound with necrotised tissue and eschar, and a fibrotic wound. This is an article about the rock music band "Circulatory System" From the Greek word eschara (scab an eschar (ˈɛskɑr is a piece of dead tissue that is cast off from the surface of the skin particularly after a burn injury Fibrosis is the formation or development of excess fibrous Connective tissue in an organ or tissue as a reparative or reactive process as opposed to a formation of Fibrous

After Negative Pressure Wound Therapy, the patient should be reevaluated every two weeks to determine future therapy. Negative Pressure Wound Therapy (NPWT is the use of sub-atmospheric pressure to promote or assist wound healing or to remove fluids from a wound site

Complications

Pressure sores can trigger other ailments, and cause patients considerable suffering and financial cost. ^[8] Some complications include autonomic dysreflexia, bladder distension, osteomyelitis, pyarthroses, sepsis, amyloidosis, anemia, urethral fistula, gangrene and very rarely malignant transformation. Autonomic dysreflexia,"AD" or "autonomic hyperreflexia" is a massive sympathetic discharge that can occur in association with Spinal cord injury Osteomyelitis is an Infection of Bone or Bone marrow, usually caused by Pyogenic Bacteria or Mycobacteria. Sepsis is a serious medical condition characterized by a whole-body inflammatory state (called a Systemic inflammatory response syndrome or SIRS caused In Medicine, amyloidosis refers to a variety of conditions in which Amyloid Proteins are abnormally deposited in organs and/or tissues Anemia ( AmE) or anæmia/anaemia ( BrE) (from the Ancient Greek grc-Latn anaîmia, meaning “without blood” is defined as a qualitative In Anatomy, the urethra (from Greek ουρήθρα - ourethra) is a tube which connects the Urinary bladder to the outside of In medicine a fistula (pl fistulas or fistulae is an abnormal connection or passageway between two Epithelium -lined organs or vessels that normally do not connect Please do not add warnings to this page about the pictures Wikipedia is not censored for taste and has a guideline preventing such warnings - WikipediaNo disclaimers in articles Malignant transformation is the process by which cells acquire the properties of Cancer. Sores often recur because patients do not follow recommended treatment or develop seromas, hematomas, infections, or dehiscence. A seroma is a pocket of clear Serous fluid that sometimes develops in the body after Surgery. A hematoma, or haematoma, is a collection of Blood outside the blood vessels generally the result of Hemorrhage, or more specifically Internal bleeding An infection is the detrimental Colonization of a host Organism by a foreign Species. Wound dehiscence is the premature "bursting" open of a Wound along surgical suture Paralytic patients are the most likely people to have pressure sores recur. Paralysed redirects here For other uses see xx Paralysed (disambiguation Paralysis is the complete loss of Muscle function In some cases, complications from pressure sores can be life-threatening. The most common causes of fatality stem from renal failure and amyloidosis. Renal failure or kidney In Medicine, amyloidosis refers to a variety of conditions in which Amyloid Proteins are abnormally deposited in organs and/or tissues

See also

• Wound healing
• Gangrene
• Liquefactive necrosis

References

1. ^ Thomas DR, Marilyn R. Wound healing, or wound repair, is the body's natural process of regenerating dermal and epidermal tissue. Please do not add warnings to this page about the pictures Wikipedia is not censored for taste and has a guideline preventing such warnings - WikipediaNo disclaimers in articles Liquefactive necrosis (or colliquative necrosis) is a type of Necrosis which is characteristic of focal Bacterial or Fungal infections Diebold and Linda M. Eggemeyer. A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3–4 pressure ulcers: A pilot study. Journal of the American Medical Directors Association, Volume 6, Issue 1, January-February 2005, Pages 46-49.
2. ^ Niezgoda, Jeffrey A. and Susan Mendez-Eastman. The Effective Management of Pressure Ulcers. Advances in Skin & Wound Care: The Journal for Prevention and Healing, Volume 19, Number 1 - Supplement (2006): 3-15.
3. ^ National Pressure Ulcer Advisory Panel Board of Directors, "Pressure ulcers in America: Prevalence, incidence, and implications for the future," in An Executive Summary of the National Pressure Ulcer Advisory Panel Monograph, Jul/August 2001, ed. Janet Cuddigan et al.
4. ^ Jiricka, MK, P Ryan, MA Carvalho, and J Bukvich. Pressure ulcer risk factors in an ICU population. American Journal of Critical Care. Vol 4, Issue 5 (1995): 361-367.
5. ^ Niezgoda, Jeffrey A. and Susan Mendez-Eastman. The Effective Management of Pressure Ulcers. Advances in Skin & Wound Care: The Journal for Prevention and Healing, Volume 19, Number 1 - Supplement (2006): 3-15.
6. ^ 510(k)s Final Decisions Rendered for January 2004, http://www.fda.gov/cdrh/510k/sumjan04.html
7. ^ Bain DS, Ferguson-Pell MW. Remote monitoring of sitting behaviour of people with spinal injury. Journal of Rehabilitation Research and Development, Vol 39, 4, July 2002, Pages 513-520.
8. ^ Brem H, Kirsner RS, and Falanga V. Protocol for the successful treatment of venous ulcers. The American Journal of Surgery, Volume 188, Issue 1, Supplement 1, July 2004, Pages 1-8.

Alexander's Care of the Patient in Surgery by Jane C Rothrock, Thirteenth Edition, 2007. Mosby

External links

• Bed Sores and Pressure Ulcers
• CNN article
• USA today article