Preventing and Treating Bedsores

Many skin conditions plague our elderly patients, but none are quite as prevalent and damaging as pressure ulcers.  A pressure ulcer is an injury to the skin and underlying tissues over a particular part of the body.  They often start as reddened areas that are noticed over bony prominences and can quickly progress to deep cavernous sores that can take months to heal.

Pressure ulcers have been a growing concern, with a marked increase in incidence in the past twenty years.  In fact, from 1993 to 2010 pressure ulcers increased by 63%.  This has many consequences to the health care system and to patients such as a longer average length of stay in the hospital, increased costs and an increased workload on staff.

Prevention of bedsores, if at all possible, is critical as treating them can be problematic and can often lead to other conditions.

Physicians will usually perform a visual exam in order to assess the likelihood of a patient developing them. There are several factors that a doctor will take into account to determine a patient’s risk level, some of which are:

• Level of mobility
• General health of patient
• Prior history of bedsores
• Nutrition
• Continence
• Blood circulation
• Mental health and state of patient
• Existing signs or symptoms of infection

As a CNA, your role in recognizing the development of a pressure ulcer and in preventing their occurrence is paramount.  You are the eyes of the nurses and doctors and are the ones most often assessing a patient’s skin, so a thorough understanding of pressure ulcers is essential.

Consequences of Pressure Ulcers

There are many consequences to the development of a pressure ulcer.  For institutions, there is an increase in the length of hospital stay, increased financial costs, and increased demands on staff.

For the patient, there is a lot of pain, as well as the many side effects of pain and analgesic use such as depression, hopelessness, fatigue, and decreased mobility potentially leading to frailty, delirium, and falls.

Pressure ulcers can also cause severe infections such as cellulitis (an infection of the skin and superficial tissues) and osteomyelitis (an infection in the bone) which may lead to sepsis and potentially death.

Risk Factors in Developing Pressure Ulcers

Pressure ulcers are generally caused by pressure being applied to a part of the skin for a long time.  The factors in developing a pressure ulcer are the intensity of the pressure, the duration it is applied, and how healthy the tissue was to begin with.

Immobility is the most common risk factor.  Patients may become immobile from illness, or because they have received certain medications such as sedatives or narcotic analgesics.  If patients are weak or over sedated, they may be unable to change positions and rely on staff to move them or to know when they should be moving.

The underlying condition of the skin is also an essential factor in the development of pressure ulcers. If patients are undernourished or dehydrated, their skin condition may not be ideal, making them more likely to develop a pressure ulcer.  Thin, friable skin may also put patients at increased risk.  Patients who are incontinent are particularly vulnerable as the acidity of urine or stool sitting on the skin may mean that less force and shorter durations lead to pressure ulcers developing more quickly.

Pressure Ulcer Stages

Pressure ulcers can go through several stages depending on the depth and which tissues are involved.  One significant factor to keep in mind when assessing a patient with deep skin tones is that the purplish color of a pressure ulcer is often difficult to detect, so it is essential to evaluate for all the other indicators, such as pain, or tissue firmness of temperature rather than relying on color alone.

Suspected Deep Tissue Injury

This is the pre-pressure ulcer stage – a stage where if noticed by the CNA may be quickly and easily reversed preventing many of the consequences of full-blown pressure ulcers.

At this stage, the skin may appear purple or maroon in color, similar in appearance to a bruise, and is localized to a specific area, usually a bony prominence such as the coccyx.  Alternatively, it may appear as a blood-filled blister.

The area is usually painful to the patient, may feel either firmer, or boggy and mushy when compared to surrounding tissues.  It is often a different temperature than surrounding tissues but may be either warmer or colder.

This stage is critical as while the skin appears intact on the surface, underneath the skin the damage has already occurred.  If these injuries are not treated right away, they will immediately progress to a stage IV pressure ulcer. In essence, the skin stays intact, but the tissue underneath is severely damaged.

Stage I

Stage 1 pressure ulcers continue to have intact skin, but that skin has a noticeable difference when compared to surrounding tissues.  It presents similarly to a suspected DTI where the skin is painful, warmer or colder than surrounding tissues, and may feel hard or soft and boggy.  This main difference is the color – Stage I ulcers are red in color and are not associated with deeper injury to the tissues, while SDTIs are purple, look like a bruise and are much worse underneath the skin.

Stage II

Stage II pressure ulcers involve a partial thickness tissue loss.  It may appear as a shiny or dry shallow open ulcer with a red or pink wound bed.  It may contain something called slough which is basically a thick yellow or tan layer over the wound bed that is made primarily of dead skin tissue.  It may also present as an open or ruptured serum-filled blister.

Stage III

Stage III pressure ulcers involve a full thickness tissue loss.  Subcutaneous fat may be visible, but bone, tendons or muscles are not exposed.  They appear as a deep crater and may involve something called undermining or tunneling, which is a continuation of the ulcer underneath the skin in either a wide band (undermining) or long tunnels.

Stage IV

These are the worst pressure ulcers which involve a full thickness tissue loss as well as exposed bone and tendons. Slough or eschar (a black layer of dead tissue) may be present, and damage has occurred to the muscle, bone or other supportive structures such as fascia, tendon, or the joint capsule.  This stage is the most difficult to treat and can cause the most severe consequences such as osteomyelitis (an infection in the bone) or sepsis and death.

Prevention & Skin Care

While the description of skin tears can leave the strongest amongst us feeling a little unwell, the reality is that skin tears are entirely preventable.  The best and easiest way to treat a pressure ulcer is to prevent it from happening or to prevent it from progressing.  As a CNA, you are the person who observes the patients skin the most and the most likely to notice the warning signs that a pressure ulcer is likely to develop.  Similarly, as prevention mostly involves care techniques and policies, you are the one who is most instrumental in implementing a prevention plan.  A good prevention plan includes skin care, repositioning and pressure redistribution, and promoting mobilization and activity.

Skin Care

The best way to prevent pressure ulcers hands down is frequent and regular assessments of the skin condition, especially over bony prominences such as the coccyx, hips, elbows, and heels.  Inspections should be done daily at a minimum, and high-risk areas should be done every time care is given.  The subtle changes that can signal the development of an ulcer can deteriorate in a matter of hours.

Patients should be bathed as frequently as possible accounting for individual factors such as incontinence (bathe more frequently) and dry skin (bathe less frequently).  If a patient is incontinent, in addition to washing them more regularly be sure to protect the skin with a barrier cream or zinc oxide cream to prevent the acidity of urine or stool from sitting directly on the skin and hastening skin breakdown.  Be sure to use plenty of moisturizers but avoid massaging bony prominences. While some people may feel that massaging helps increase circulation, the reality is that you want to minimize the amount of pressure applied to high-risk areas. Massaging a bony prominence only applies more pressure and friction to an already sensitive area.

Pressure Redistribution

Most CNAs are familiar with the standard turning schedule for bedridden patients: turn and reposition every 2 hours.  Care should be taken to keep bony prominences from touching, such as a pillow between the knees.  You never want to have someone all the way over on their side, only turn them about 30 degrees to avoid putting pressure on their hips.  Don’t forget the feet – always be sure to raise heels off the bed or apply heel poseys to relieve pressure.

With increased workload and demands on CNAs, it can be easy to lose track of time and forget to turn someone on time.  Try implementing a written schedule on your unit to help communication and ease the workload.  Also – don’t forget about your wheelchair-bound patients too – be sure to help them change positions in their chair every 2 hours, especially if they have sensory problems and aren’t able to tell when it is time to move.

Mobilization

Finally, whenever possible encourage patients to mobilize frequently.  This improves circulation and promotes pressure redistribution, decreasing the chance of tissue damage from prolonged pressure.

Skin tears can be a devastating condition for both patients and staff, and once established can be very difficult to treat.  As a CNA you are the first line of defense against pressure ulcers – you are often the first to the notice signs and are most involved in care, including the frequency of turning and positioning, as well as bathing schedules.  Knowledge of the symptoms and stages of pressure ulcers is paramount in our ability to prevent and treat them.  With your expert care and attention to detail pressure ulcers can be easily prevented and avoided.

Treatment

Once a bedsore or pressure ulcer has been detected, it is difficult to treat since open wounds are slow to heal even in mobile or otherwise healthy people. Even after a bedsore has healed the area often experiences irreparable damage with the skin remaining quite irregular. In cases where patients are being cared for at home a certified nursing assistant or health care aid may not be present 7 days a week and it is therefore vital that others caring for the patient continue the treatment and regularly check for bedsores.

As soon as a bedsore has been detected the pressure to that spot must be eliminated immediately. There are a couple of ways this can be done.

• Specific supportive devices such as mattresses, pads, specialized beds or cushions can help relieve the pressure. Which devices are used will depend on how far the sore(s) have advanced, the size of the patient as well as his/her mobility.
• Changing the position of the patient regularly is critical. It is important to protect the wound with padding when moving the patient in order to avoid friction to the affected area.

When dealing with patients of limited mobility, it is highly recommended that every certified nursing assistant review bedsore procedure that were taught in their CNA classes. This can often be accomplished through online CNA certification review programs.