Pressure ulcers or “bed sores” are caused by pressure against the skin that prevent an adequate amount of blood to reach the skin. Based upon the publications and research of the Mayo Clinic, there are three main causes of pressure ulcers:
Constant pressure. When the skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, the pressure may be greater than the pressure of the blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to tissues. Deprived of these essential nutrients, cells of the skin and other tissues are damaged and may eventually die (“necrosis”). This kind of pressure tends to happen in areas that aren’t well padded with muscle or fat and that lie just over a bone, such as the spine, tailbone (coccyx), shoulder blades, hips, heels and elbows.
Friction. Friction is the resistance to motion. When a person changes position or is handled by care providers, friction may occur when the skin is dragged across a surface. The resistance to motion may be even greater if the skin is moist. Friction between skin and another surface may make fragile skin more vulnerable to injury.
Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a hospital bed is elevated at the head, a person can slide down in bed. As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction. This motion may damage tissue and blood vessels, making the site more vulnerable to damage from sustained pressure.
While these are the three main causes of pressure ulcers, our seniors residing at nursing homes are even more at risk. The skin of older adults is generally more fragile, thinner, less elastic and drier than the skin of younger adults. Also, new skin cells are usually generated more slowly. All of these conditions of the skin make it more vulnerable to damage. Further, many nursing home residents are deprived of proper nutrition and hydration at the nursing home. An adequate amount of fluids, calories, protein, vitamins and minerals in the daily diet are important for maintaining healthy skin and preventing the breakdown of tissues. When a nursing resident is not receiving the nutrition and/or hydration he needs, his skin becomes more vulnerable to pressure ulcers.
Many nursing home residents are incontinent, or are unable to control urination and/or bowel movements. Problems with bladder control can greatly increase the risk of pressure sores because the skin may frequently be moist, making it more likely to break down. Bacteria from fecal matter can cause serious local infections and lead to life-threatening infections affecting the body in general. Additionally, many of the health problems that afflict our seniors make them prone to pressure ulcers. Because certain health problems, such as diabetes and vascular disease, affect circulation, parts of the body may not receive adequate blood flow, increasing the risk of tissue damage. A large percentage of the nursing home population is afflicted with Alzheimer’s disease or dementia. People whose mental awareness is lessened by disease, trauma or medications are often less able to take the actions needed to prevent or care for pressure sores.
In addition to the pain and suffering that accompanies the wound itself, many other complications can arise from a pressure ulcer impairing the health of our seniors.
- Sepsis. Sepsis occurs when bacteria enters the bloodstream through the broken skin and spreads throughout the body — a rapidly progressing, life-threatening condition that can cause organ failure.
- Cellulitis. This acute infection of the skin’s connective tissue causes pain, redness and swelling, all of which can be severe. Cellulitis can also lead to life-threatening complications, including sepsis and meningitis — an infection of the membrane and fluid surrounding the brain and spinal cord.
- Bone and joint infections. These develop when the infection from a pressure sore burrows deep into the joints and bones. Joint infections (septic or infectious arthritis) can damage cartilage and tissue, and bone infections (osteomyelitis) may reduce the function of the joints and limbs.
- Cancer. Another complication is the development of a type of squamous cell carcinoma that develops in chronic, nonhealing wounds (Marjolin ulcer). This type of cancer is aggressive and usually requires surgical treatment.
So how can you prevent your loved one from getting a pressure ulcer at the nursing home? First, you can schedule a meeting with the nursing home administrator and your loved one’s “care team” to discuss what treatment plan they will put in place to prevent pressure ulcers or skin tears. Position changes are key to pressure sore prevention. These changes need to be frequent, repositioning needs to avoid stress on the skin, and body positions need to minimize the risk of pressure on vulnerable areas. Other strategies include skin care, regular skin inspections and good nutrition.
Repositioning in a wheelchair includes the following recommendations:
- Frequency. People using a wheelchair should change position as much as possible on their own every 15 minutes and should have assistance with changes in position every hour.
- Self-care. If the resident has enough strength in his upper body, he can do wheelchair push-ups — raising his body off the seat by pushing on the arms of the chair.
- Specialized wheelchairs. Pressure-release wheelchairs, which tilt to redistribute pressure, provide some assistance in repositioning and pressure relief.
- Cushions. Various cushions — including foam, gel, and water- or air-filled cushions — can relieve pressure and help ensure that the body is appropriately positioned in the chair. A physical therapist can advise on the appropriate placement of cushions and their role in regular repositioning.
Repositioning for a person confined to a bed includes the following recommendations:
- Frequency. Repositioning should occur every two hours.
- Repositioning devices. People with enough upper body strength may be able to reposition themselves with the assistance of a device such as a trapeze bar. Using bed linens to help lift and reposition a person can reduce friction and shearing.
- Special mattresses and support surfaces. Special cushions, foam mattress pads, air-filled mattresses and water-filled mattresses can help a person lie in an appropriate position, relieve pressure and protect vulnerable areas from damage. A resident’s doctor or other care team member can recommend an appropriate mattress or surface.
- Bed elevation. Hospital beds that can be elevated at the head should be raised no more than 30 degrees to prevent shearing.
- Protecting bony areas. Bony areas can be protected with proper positioning and cushioning. Rather than lying directly on a hip, it’s best to lie at an angle with cushions supporting the back or front. Cushions should also be used to relieve pressure against and between the knees and ankles. Heels can be cushioned or “floated” with cushions below the calves.
Protecti
ng and monitoring the condition of the skin is important for preventing pressure sores and identifying stage I sores before they worsen.
- Bathing. Skin should be cleaned with mild soap and warm water and gently patted dry. Or a no-rinse cleanser can be used.
- Protecting skin. Skin that is vulnerable to excess moisture can be protected with talcum powder. Dry skin should have lotion applied.
- Inspecting skin. Daily skin inspection is important for identifying vulnerable areas of skin or early signs of pressure sores. Care providers usually need to help with a thorough skin inspection, but people with more mobility may be able to inspect their skin with the use of a mirror.
- Managing incontinence. Urinary or bowel incontinence should be managed to prevent moisture and bacterial exposure to skin. Care may include frequently scheduled assistance with urinating, frequent diaper changes, protective lotions on healthy skin, urinary catheters or rectal tubes.
A resident’s doctor, dietitian or other members of the care team can recommend dietary changes that can help improve the health of a resident’s skin during their nursing home stay.
- Diet. A nursing home resident may need to increase the amount of calories, protein, vitamins and minerals in their diet. A doctor may also prescribe dietary supplements, such as vitamin C and zinc.
- Fluids
. Adequate hydration is important for maintaining healthy skin. The resident’s care team can advise on how much fluid to drink and signs of poor hydration, such as decreased urine output, darker urine, dry or sticky mouth, thirst, dry skin, or constipation. - Feeding assistance. Some people with limited mobility or significant weakness may need assistance with eating in order to get adequate nutrition.
If you or a loved one developed a pressure ulcer during their nursing home stay, feel free to contact our office to discuss what happened. Or, if you have additional questions or concerns about pressure ulcers or “bed sores” feel free to email Argento Law Group, P.C. at solutions@argentolaw.com.
