Bedsores (bedsores)

Decubitus or bedsores are tissue damage caused by sustained pressure on an area of ​​the skin. Elderly bedridden people are particularly at risk. Information on diagnosis, symptoms and therapy

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Pressure ulcers - in a nutshell

A decubitus is a skin ulcer that is caused by pressure damage on the skin on the skin. This pressure damage is caused by the skin lying on one spot for too long, which leads to circulatory disorders. Bedridden people or people who are dependent on wheelchairs are particularly at risk. If there are other general risk factors for poor blood circulation, you are particularly at risk of developing pressure ulcers.

The pressure sores can grow to a considerable extent, cause pain and even be life-threatening. The symptoms are divided into four degrees of severity. Permanent reddening of the skin is one of the early symptoms.

The therapy is often very tedious. The most important measure is pressure relief through frequent changes of position and storage measures. Wound care depends on the condition and depth of the wound and always belongs in expert hands. Conservative (without surgery) or surgical procedures are used. A pressure ulcer can be avoided through preventive measures (decubitus prophylaxis).

What is a pressure ulcer?

A pressure ulcer (pressure ulcer) is caused by continuous, long-term pressure on an area of ​​the skin, which results in local damage to the skin and / or the underlying tissue. These are preferably locations where there are bony protrusions underneath. The skin area is no longer adequately supplied with blood due to the pressure damage. This causes skin and tissue damage. Bedridden people and people who sit a lot - for example in wheelchairs, for example - are at risk. Sick, weakened or old people are particularly affected, as well as people who suffer from paralysis, for example after a stroke.

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Causes: How does a pressure ulcer occur?

For example, if we lie on our back in bed, there is particularly high pressure on some areas of the skin - mostly on the back of the head, back, shoulders, elbows and heels. These are areas with prominent bone portions and little soft tissue coverage. At these pressure points, the blood vessels in the skin are compressed a little by our own body weight, so that the blood circulation in the skin deteriorates. In the short term, that's not a problem at all. As soon as we move, for example turn on our side, the pressure is distributed differently again. The previously stressed areas of the skin are now relieved of pressure and recover. In general, the skin can therefore tolerate external pressure quite well. It only becomes problematic if it is squeezed for a long time, for example due to being bedridden. The pressure on an area of ​​the skin lasts too long and there is a serious lack of supply to the skin. The tissue underneath can also die within hours.

Pressure ulcer risk: This is where bedridden people are particularly easily sore

© W & B / Ulrike Möhle

Vulnerable skin areas

Decubitus occurs preferably on areas of the skin that are exposed to particularly high pressure loads when lying or sitting for long periods of time. In addition, regions where the skin is close to the bone are very susceptible to bedsores. Here the skin is pressed directly against the bones when there is pressure from the outside, ie without "damping" by muscles or fatty tissue.

There is also an increased risk of bedsores in skin folds. In the worst case, poorly fitted prostheses, casts that are too tight, wrinkles in clothing, catheters, infusion tubes or venous access exert local pressure on certain areas of the skin - and thus lead to bedsores. Shear forces are also problematic: if a person in need of care gradually slides down on his chair, for example, he rubs and rubs his skin on the back on the armrest. This also promotes pressure ulcers.

Areas susceptible to bedsores in bedridden people are, for example:

  • Heels
  • ankle
  • knee
  • Tailbone, sacrum
  • Ischium
  • Iliac crest
  • Spinous processes of the spine
  • shoulder
  • Elbow
  • Back of the head

Risk factors for a pressure ulcer

The risk of bed sores is increased by certain influences. These include factors that can generally promote skin damage:

  • Old age
  • Diabetes mellitus
  • Weakened by other diseases
  • Circulatory disorders
  • Malnutrition and dehydration ("dehydration" due to insufficient fluid intake)

Another risk factor is a previous pressure ulcer in the medical history. In this case, the affected skin region has a permanently increased risk of new bedsores.

Symptoms: what symptoms does a pressure ulcer cause?

The symptoms of a pressure ulcer depend on the extent of the disease. The pressure ulcers are divided into four degrees of severity (see separate box: Classification). They range from lighter, more superficial skin changes to severe tissue damage, including underneath the skin. Pronounced ulcers can irreversibly destroy muscles, tendons, or even bones. If the pressure ulcer is not recognized in time, there is a risk of serious complications such as severe infections involving the bone, bone marrow or dangerous blood poisoning (sepsis). In very rare cases, long-term (chronic) wounds can develop a so-called Marjolin ulcer (squamous cell carcinoma in chronic wounds). This is a malignant skin cancer. It can take ten to 25 years for a cancerous tumor to appear in a chronic wound.

Symptom pain?

Pressure sores can be painful. But that doesn't always have to be the case. Sometimes those in need are given strong pain relievers for other reasons or are less conscious due to illness. Then, as a caregiver, you cannot rely on those affected noticing their sore skin for themselves.

Classification of pressure ulcers - according to EPUAP (European Pressure Ulcer Advisory Panel)

  • Grade 1: Reddening that cannot be pushed away

If there is a first-degree pressure ulcer, there is permanent reddening of the skin in the affected area, which remains even when the pressure is relieved. In addition to the reddening, other changes to the surrounding skin can be noticed on the affected skin area. Changes in the texture of the skin (harder or softer), temperature differences (colder or warmer) or increased sensitivity to pain may be noticed. The skin surface is still intact in this phase of bedsore.

  • Grade 2: partial loss of skin

In the second-degree pressure ulcer, parts of the skin are already defective. An open area with a deeper skin defect (ulcer, ulcer) with a red or pink wound base or blistering can be seen. The damage is still limited to the superficial layers of the skin (epidermis and parts of the dermis).

  • Grade 3: Loss of all skin layers

In the case of third-degree pressure ulcers, all layers of the skin are destroyed. The subcutaneous fatty tissue can be seen depending on the location. The resulting wound is deep.

  • Grade 4: Complete loss of tissue

In its most pronounced form, the loss of tissue extends into deeper tissue structures. Muscles, bones and tendons are visible. There may be a covering or scab over it. The deep wounds can spread over muscles and adjacent tissue (fascia, tendons, joint capsule) and lead to bone inflammation (ostitis) or bone marrow inflammation (osteomyelitis).

Pressure ulcers - degrees of severity in pictures

© Mauritius Images / Photoresearchers

TO THE PICTURE GALLERY

© Mauritius Images / Photoresearchers

Pressure ulcer grade 1:

There is permanent reddening of the skin. There is no skin defect yet.

© Mauritius Images / Photoresearchers

Decubitus grade 2:

There is a defect in the skin. This can appear as an ulcer or through the formation of blisters.

© Mauritius Images / Photoresearchers

Decubitus grade 3:

Here the defect extends beyond the layers of the skin. Adipose tissue underneath may be visible.

© Mauritius Images / Photoresearchers

Pressure ulcer grade 4:

The tissue defect extends deeply over the skin layer. Muscles, tendons, and bones can be visible.

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Diagnosis: How is a pressure ulcer diagnosed?

  • Medical history and clinical examination

Diagnosing pressure ulcers early is important to stop tissue damage and prevent complications such as infection. In addition to a medical anamnesis (conversation to record the history of an illness), in which attention is also paid to possible risk factors such as diabetes mellitus, the skin is examined and assessed for redness or visible wounds. The presence of signs of infection such as fever is also examined.

A pressure ulcer can develop anywhere on the body. However, some parts of the body are particularly prone to bedsores in bedridden people. These should be thoroughly examined by the carer on a regular basis. These include, for example, the heels, shoulders, the back of the head, the tailbone and the sacrum (see chapter Symptoms).

In addition, areas of skin that are exposed to particular stress from prostheses, catheters, infusion tubes or plaster casts must also be examined.

  • Laboratory chemical / bacteriological / histological examinations

Further examinations can be useful from the second degree of severity of a pressure ulcer disease and existing signs of infection. This includes a blood sample and swabs from the wound in order to identify a germ, if necessary. If a local skin area appears suspicious for cancer (suspected malignancy), a tissue sample is sent for histological examination.

  • Imaging procedures

Usually, pressure ulcer is a clinical diagnosis and is determined by medical history and examination. In rare cases, for example to clarify whether there is an inflammation of the bone, other imaging tests are used. Depending on the question, these can be x-rays, MRI or CT examinations or an ultrasound examination (sonography).

Tip for family carers

The finger test: If you press the reddened area carefully and briefly with your finger, it no longer turns white. The reddening cannot be pushed away - a sign of the onset of pressure ulcers.

Therapy: How is a pressure ulcer treated?

Treatment of a pressure ulcer depends on its severity; the earlier a pressure ulcer is detected, the better the chances of recovery. Pressure ulcer therapy until it has completely healed can be very tedious and requires a lot of patience.

Conservative treatment

Treatment without surgery (conservative) is possible for severity grades 1 and 2. If the skin is still intact, pressure relief is necessary until the skin has healed completely. From the second stage onwards, wound dressings are also used.

  • storage

Here, complete pressure relief is the most important treatment measure in the foreground. For bedridden people, this is done, among other things, through targeted positioning (see section Preventing bedsores). The positioning must be chosen individually, since existing concomitant diseases are also decisive for the choice. The aim is complete healing and the regaining of a closed skin surface. If this is not possible (especially in grade 2) or if the wound worsens, surgical therapy may be necessary.

  • Wound dressings / wound dressings

When changing dressings, care must be taken to ensure that the wound is not torn open again (atraumatically). There should also be as long a period of time as possible (over 24 hours) between dressing changes so that the wound can heal. If this is not possible because the wound is too wet, a so-called local negative pressure treatment (see below) can be useful. Treatment around the wound to protect the skin is also appropriate.

There are a number of different materials on the market for wound dressings. The choice of preparations is to be made individually depending on the wound conditions.It is important to say that pressure ulcer therapy is a complex matter and must therefore be accompanied by specially trained staff (doctors, special nurses, special consultations). Doing your own experiments with any bandages and ointments is prohibited.

  • Wound irrigation

The aim is to reduce germs. Certain solutions (physiological saline solutions or Ringer's solutions) can be used for pure rinsing of the wound. Tap water should only be used in certain cases (filter systems and guaranteed sterility).

  • Wound cleansing

Depending on the nature of the wound, cleaning the bottom of the wound is sometimes useful. Various methods are available for this (autolytic, osmotic, biosurgical). The autolytic ("self-dissolving") and osmotic ("relating to osmosis", here certain particle distributions in the tissue are used) are special wound dressings and gels. In biosurgical wound cleaning, special, germ-free (sterile) cultivated maggots are placed in the wound, which clean the wound base from dead cells. The aim of all procedures is to clean the wound base and enable it to heal.

  • Local Negative Pressure Wound Therapy (NPWT)

Various systems are available for this. What they all have in common is that the wound base is first surgically cleaned sterile. Then the selected system is applied to the cleaned wound, sealed airtight with a film and a pump is applied to the film dressing that has been created, which creates a negative pressure. The negative pressure ensures that the wound fluid (wound secretion) drains away and is intended to promote blood circulation and the healing process. Local negative pressure therapy (vacuum therapy) can be used to reduce the size of wounds that have been treated conservatively. It can also be used to prepare (improve the wound bed) for surgical treatment.

It is imperative that swabs are taken from the wound at regular intervals. If there are indications of an infection, antibiotic therapy can then be started, for example.

Operative treatment

Surgical treatment of the pressure ulcer takes place in the case of deeper pressure ulcers, i.e. with a pressure ulcer grade 3 or 4. If the patient refuses the operation or speaks other things such as general condition and concomitant diseases against an operative procedure, conservative therapy can also be used.

  • Wound conditioning

So-called wound conditioning is about the restoration of a good wound bed, on the bottom of which healing (wound granulation) can then take place. Therefore, the wound base must first be surgically cleaned by surgically removing the dead tissue (debridement). Sometimes several operations are necessary for this. In addition, methods from conservative treatment are used, such as special wound dressings or negative pressure therapy.

  • Operative wound closure

A completely clean wound can be closed with a so-called flap. For this purpose, intact skin flaps are shifted over the wound or reinserted. It should be mentioned that there can be local complications after surgical closure. This includes the re-opening of the seam, accumulation of fluid, bruising or the death of the dislocated skin (necrosis). It is therefore essential to fully relieve the pressure after the operation, otherwise the tissue cannot heal properly.

Prevention: How can you prevent pressure ulcers?

There are various measures to prevent pressure ulcers (pressure ulcer prophylaxis). In hospitals, rehabilitation facilities and nursing homes, endangered patients should be motivated to exercise as much as possible and, if necessary, regularly repositioned or repositioned in order to avoid bedsores. In addition, your skin - especially at risk areas - should be checked closely for changes that might be suspicious of pressure ulcers (see chapter Symptoms). Good skin care also helps prevent bedsores.

Preventing pressure ulcers: tips for caregivers

Those who care for themselves at home are faced with a big task. It is important to assess the situation realistically: Can I actually trust myself to take care of myself - possibly around the clock - on my own? What support is there, for example through outpatient care services? What do I need to know in order to provide the best possible care for the person in need of care?

Courses for nurses on how to provide nursing services, for example, offer helpful information. Here, carers can acquire important basic knowledge and learn tried and tested storage techniques. Many participants also find it a great relief to exchange ideas with other people affected.

Crucial: movement and consistent storage

Relatives should always encourage the person in need of care to exercise as much as possible - as far as they can. Suggestions for more activity are, for example, visiting relatives or friends, reading aloud from the newspaper or looking at old photos together. The patient may be able to sit on the edge of the bed to eat instead of lying down. If feasible, it is advisable to alternate between lying in bed and sitting in a well-padded chair more frequently. It is advisable to adapt a suitable seat cushion (orthopedic specialist shop). Perhaps it is also possible to take a few steps with the patient every now and then. The more changes in position, the better.

If the person concerned is no longer able to move sufficiently, the caregiver must support him: The most important measure to counteract a pressure ulcer is consistently repositioning bedridden people or transferring people sitting in wheelchairs. Such precautions are intended to prevent individual areas of the skin from being permanently exposed to excessive pressure. How often the storage has to be changed and which storage is possible varies from person to person. The doctor and professional nurses can best assess this. Storage techniques and optimal time intervals should be discussed with them. You can see examples of repositioning techniques further down this page.

Alternating pressure mattresses may be a possible support: Such anti-decubitus mattresses consist of several air chambers. An automatic system alternately fills these chambers with air. The affected person lies on one of the air chambers, sometimes on the other, which reduces the pressure on individual areas of the skin. However, such mattresses are by no means a substitute for regular repositioning. Special seat rings or upholstery also make sense as additional aids.

Optimal care

In order to prevent pressure ulcers from developing, it is also important to take good care of your skin. Sweat, urine (in incontinent people) or wound secretions can possibly soften the skin and thereby increase the risk of bedsores. But very dry skin is also more sensitive and therefore possibly more susceptible. It is best to discuss what the optimal skin care looks like with your doctor or a nurse. Less is often more. In most cases, a soap-free, skin-friendly washing lotion and - for intact skin - a moisturizing skin protection ointment without skin-irritating substances are sufficient. The pharmacy can also help with the selection of suitable care products. When it comes to body care, it is better not to rub and rub too much, this could possibly put additional strain on the skin. Also important: Make sure you use soft, breathable, skin-friendly bed linen (for example made of cotton) and pull the sheets as wrinkle-free as possible.

Other risk factors for pressure ulcers include dehydration, malnutrition, and the use of certain medications such as sedatives. In order to prevent bedsores, care should be taken to ensure adequate fluid intake and an appropriate, vitamin-rich and balanced diet. The doctor can also decide whether all drugs are optimally adjusted. Caution: Do not dispose of drugs on your own. If there is diabetes mellitus (diabetes), the blood sugar level is also crucial. Poor blood sugar levels increase the risk of skin damage in the long term.

Caregivers should check the patient's skin for bedsores on a daily basis - especially at risk areas (see chapter causes). At the first possible signs of bedsores, the following applies: In no case should you wait, but ask your doctor or a professional nurse for advice immediately!

Examples of storage

Attention: The graphics serve only as examples. Which storage is suitable in each individual case and at what intervals it has to be changed should always be discussed with a professional nurse or a doctor! This is because accompanying illnesses are also of interest when it comes to choosing the right position.

This is how the 30-degree storage works

© W & B / Ulrike Möhle

30 degree storage

Gently turn the patient on his side. Slide a flat pillow into his back along his spine. Place a second pillow on the same side between your thighs. After the agreed time, change sides.

So the heel is stored freely

© W & B / Ulrike Möhle

Free heel

Roll up a towel from both sides. Place your foot in the center of the towel roll. The heel is not on. However, it must be ensured that no other body region is stressed by the positioning measure.

Dr. Michael Ruggaber

© W & B / private

Our advisory expert:

Dr. Michael Ruggaber, specialist in plastic and aesthetic surgery as well as hand surgery. Head of these areas at the Bodensee campus - Friedrichshafen and Tettnang.

Swell:

  • Association of the Scientific Medical Societies in Germany (AWMF), cross-sectional-specific pressure ulcer treatment and prevention, as of 07/2017. Online: https://www.awmf.org/uploads/tx_szleitlinien/179-008l_S1_Querschnitt specific_Dekubitusverarbeitung_Dekubituspraevention_2017-08.pdf (accessed on June 24, 2019)

Important NOTE:
This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.

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