Runnin head: BEDSORES 1

Bedsores
Anabel, Unquid
Dade Medical College



BEDSORES 2

Abstract

Bedsores also known as pressure sores or pressure ulcers are injuries to the skin and underlying
tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that
covers bony areas of the body, such as the heel, ankles, hips or buttocks. They also develop due
to repeated incidents of blood flow interruption and not enough recovery time in between. The
lack of blood circulation may lead to tissue damage and eventually cell death. The easiest way to
identify the sore its by noticing redness in the affected area. When pressure is high enough to
damage the cell membrane of muscle cells pressure ulcer may develop. The muscle cells die as a
result and skin fed through blood vessels coming through the muscle die. This is the deep tissue
injury form of pressure ulcers and begins as purple intact skin.Bedsores are more often encounter
in clients with a medical condition that limits their motor abilities such as changing positions or
even walking, the need of using a wheelchair or being confined to a bed make them more liable
to develop bedsores. Due to the quick development of bedsores they become difficult to treat.
The best way to treat bedsores is by preventing care using new and improved strategies and by
educating the client and relatives on how to cure and prevent bedsores. Bedsores are categorized
in four stages depending on their severity. These four stages are as follow:






BEDSORES 3

Bedsores
Bedsores also known as pressure sores or pressure ulcers are injuries to the skin and
underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop
on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks. They also
develop due to repeated incidents of blood flow interruption and not enough recovery time in
between. The lack of blood circulation may lead to tissue damage and eventually cell death. The
easiest way to identify the sore its by noticing redness in the affected area. When pressure is high
enough to damage the cell membrane of muscle cells pressure ulcer may develop. The muscle
cells die as a result and skin fed through blood vessels coming through the muscle die. This is the
deep tissue injury form of pressure ulcers and begins as purple intact skin. (Mayo, 2012)
Bedsores are more often encounter in clients with a medical condition that limits their
motor abilities such as changing positions or even walking, the need of using a wheelchair or
being confined to a bed make them more liable to develop bedsores. Due to the quick
development of bedsores they become difficult to treat. The best way to treat bedsores is by
preventing care using new and improved strategies and by educating the client and relatives on
how to cure and prevent bedsores. Bedsores are categorized in four stages depending on their
severity. (David C. Dugdale)These four stages are as follow:

Stage I
The beginning stage of a pressure sore has the following characteristics:
The skin is intact.
BEDSORES 4

The skin appears red on people with lighter skin color, and the skin doesn't briefly lighten
(blanch) when touched.
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 site may be painful, firm, soft, warmer or cooler compared with the surrounding skin.
Stage II
The stage II ulcer is an open wound:
The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged
or lost.
The pressure ulcer may appear as a shallow, pinkish-red, basin-like wound.
It may also appear as an intact or ruptured fluid-filled blister.
Stage III
At this stage, the ulcer is a deep wound:
The loss of skin usually exposes some amount of fat.
The ulcer has a crater-like appearance.
The bottom of the wound may have some yellowish dead tissue (slough).
The damage may extend beyond the primary wound below layers of healthy skin.
Stage IV
A stage IV ulcer exhibits large-scale loss of tissue:
BEDSORES 5

The wound may expose muscle, bone and tendons.
The bottom of the wound likely contains slough or dark, crusty dead tissue (eschar).
The damage often extends beyond the primary wound below layers of healthy skin.

The first step to do in order to treat any bedsore is to find the cause of pressure and
release it. The main strategies to release pressure are, repositioning and support surfaces.
Repositioning consist in changing a person position to the correct one if in a wheelchair every 15
min by himself and with help every hour and if in bed every 2 hours, a lifting device may be
used to avoid friction or damaging the affected area. In order for sores or wounds in general to
heal correctly all damaged tissue needs to be removed. Depending on the severity of the wound
the right treatment can be determined. Some of these treatments are:
Surgical debridement involves cutting away dead tissues.
Mechanical debridement uses one of a number of methods to loosen and remove wound debris,
such as a pressurized irrigation device, a whirlpool water bath or specialized dressings.
Autolytic debridement, the body's natural process of recruiting enzymes to break down dead
tissue, can be enhanced with an appropriate dressing that keeps the wound moist and clean.
Enzymatic debridement is the use of chemical enzymes and appropriate dressings to break down
dead tissues. (Shehzad Topiwala)
Cleaning and dressing of wounds its a very important part of the treatment. Cleaning is
essential to prevent infections and maintain wounds hygiene. A stage one sore can be clean as
simple as using water and soap, meanwhile a stage two or more advance wound needs to be
BEDSORES 6

clean using a saline solution every time the dressing is changed. Dressing promotes healing by
keeping a wound moist, creating a barrier against infection and keeping the surrounding skin dry.
A variety of dressings are available, including films, gauzes, gels, foams and various treated
coverings. A combination of dressings may be used. Other interventions used are pain
management, antibiotics a healthy diet and muscle spam relief. If the pressure sore does not heal
after the before mentioned then surgical repair its necessary. Surgical repair on bed sores
consists on improve the hygiene and appearance of the sore, prevent or treat infection, reduce
fluid loss through the wound, and lower the risk of cancer. (Mayo, 2012)
Bed sores have a good and positive outlook. Most of bedsores stage two and lower are
healed within a couple of week with simple treatments. If these treatments and methods fail with
a stage IV or higher bed sore then the solution is reconstructive surgery to repair the damaged
area. (Mayo, 2012)
Nursing care plan
Assessment: subjective: patient stated I feel some pain, more like a pressure and
moisture very low in my back.
Objective: facial grimace, sacral wound measuring 3.9 by 4.3 cm with exposure of skin
tissue dermis and epidermis.
Nursing diagnosis: Impaired skin integrity related to immobility as evidenced by
destruction of skin layers in the sacral area.
Planning: short term goal: patient receives stage appropriate wound care and experiences
pressure reduction.
Long term goal: patient experiences healing of pressure ulcer.

BEDSORES 7


Implementation:
1- Assess the specific risk factors for pressure ulcers (even patients who
already have pressure ulcer continue to be at risk for further injury.)
2- Assess for fecal and urinal incontinence (the urea in urine turns into
ammonia within minutes and is caustic to the skin. Stool may contain
enzymes that causes skin breakdown.)
3- Assess the condition of wound edges and surrounding tissue (surrounding
tissue may be healthy or may have various degrees of impairment. Healthy
tissue is necessary for the use of local wound care products requiring
adhesion to the skin.)
Evaluation:
1- Clients specific risk factors are immobility and poor nutritional status. Turn
patient every 2 hours and request a consult with a nutritionist.
2- Patient is fecal and urinal incontinence. Client has to be change at least every 2
hours.
3- Surrounding tissue is healthy and in good condition, which is a good sign of
wound healing.





BEDSORES 8


References
Clinic, M. (2012, 12 01). Mayo Clinic. Retrieved 07 25, 2013, from www.mayoclinic.com
David C. Dugdale, I. M. (n.d.). http://www.ncbi.nlm.nih.gov. Retrieved 07 25, 2013, from
http://www.ncbi.nlm.nih.gov: http://www.ncbi.nlm.nih.gov
Shehzad Topiwala, M. C. (n.d.). http://www.nlm.nih.gov. Retrieved 07 25, 2013, from
http://www.nlm.nih.gov: http://www.nlm.nih.gov