Bedsores and the Accountability of the Family
The most commonly asked question by family members who come to see me after they have discovered their loved one has formed a large bedsore while at a nursing home is, how did this happen and was it preventable?
The short answer is nearly always, yes. First and foremost it is incumbent upon the family of a person in a nursing home to visit often and check their loved one for signs that a bedsore is beginning to form. The trouble areas most susceptible to the formation of bedsores are the areas of the body upon which the most pressure is exerted, hence sometimes bedsores are commonly referred to as pressure sores. The sacrum or tail bone (coccyx) is an area of the body particularly at risk for developing a pressure sore. The bottoms of the heels are also a common area of concern. Family members should check these areas of their loved one every time they visit. Trusting that the nursing staff is doing the same can be a critical mistake. Most facilities are understaffed with substandard caregivers who frankly may not care about doing a vigilant job of keeping your loved bedsore free. Discovering a bedsore before it reaches advanced an stage is crucial because once a bedsore evolves to a later stage of development the odds of the patient ever fully healing diminish exponentially. By the time a pressure sore reaches stage IV the patient has only a 50% will ever fully heal. Bedsores are classified in stages from I to IV. Stage I is the earliest stage and is typified by superficial redness and may be hot to touch. Stage II is characterized by damage to the dermis but no deeper. This stage may look like a small blister. If a pressure sore is found at this stage it should be relatively easy to control in a patient with a solid and intact vascular system. The key element to consider when addressing a bedsore during the early stages of development is diet. A resident's protein levels must be stable in order to facilitate adequate healing. This oftentimes requires a special diet with high protein content. The staff must be vigilant about monitoring a resident's liquid and nutritional intake. This type of monitoring should be made part of the care plan however, the fact that it is does not mean that it is actually being done. Many times the chart will indicate that the patient is eating 75% of their food when in fact they are hardly eating anything. Many times the staff does not even look at the resident's plate to make an accurate assessment instead writing whatever will require them to do nothing in response to the patient's actual needs.
Once the bedsore progresses to stage III it is almost a foregone conclusion that it will reach stage IV. Stage III involves full thickness skin loss involving damage to the underlying tissue. The connective tissue is not yet disturbed but that is to come next when the ulcer reaches stage IV.
Stage IV involves full thickness skin loss with extensive damage to the underlying muscle tissue. The sore tunnels through the muscle until the bone is exposed. It is commonplace that sepsis (blood infection) will set in as a result of the open exposure of the internal muscles and bone. Once sepsis takes root the infection can become systemic resulting in renal failure and death. Many times the underlying bony structures become infected. This orthopedic infection is called osteomyelitis.
Osteomyelitis means an infection of the bone or bone marrow caused by invasive bacteria. Remember your skin is your first and one of the most important defenses that your body has against pathogens in the outside world. Once that defense is taken down you are at an increased risk for all sorts of problems. Osteomyelitis can degrade bony material to such an extent that amputation of the affected body part may be needed.
The methods of caring for bedsores and the range of time it takes for one to heal varies depending on the stage, nature and severity of the sore and the general health and co-morbidity of the patient.
Generally the first form of treatment of a bedsore that has progressed past Stage II is debridement. This is the removal of necrotic tissue contained within the wound. Debridement
The removal of necrotic tissue is an absolute must in the treatment of pressure sores. Because dead tissue is an ideal area for bacterial growth, it has the ability to greatly compromise wound healing. There are at least seven ways to excise necrotic tissue.
1. Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes.
2. Biological debridement using maggots is the use of medical maggots to feed on the necrotic tissue in an effort to clean the wound. This method has generally fallen out of favor however, is still considered a medically permissible option for wound care.
3. Chemical debridement, or enzymatic debridement, is the use of enzymes that promote the dissolution or removal of necrotic tissue.
4. Mechanical debridement is the use of outside force to remove dead tissue. This involves the packing of a wound with wet dressings that are allowed to dry and then are removed.
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.
Flap Surgery
A surgical intervention of last resort is where skin is removed from another part of the person's body and applied (transplanted or grafted) over the sore. Skin transplantation or grafting can help prevent infections and speed healing. However, it may be too risky for people who are frail or undernourished.
If all other treatments are ineffective, an area of skin next to the pressure sore is cut and folded over the sore. This procedure is called flap surgery.
Conclusion
Families need to remember that it is much easier to prevent the formation of a serious decubitus ulcer/bedsore then it is to treat one that has already formed. Once formed, a bedsore on an acutely ill patient with serious co-morbitities can be difficult to control. This is especially true where a sick patient is unable to ingest copious amounts or protein which promotes healing. Families need to be responsible and accountable to their loved one to see that they are getting the care they need and deserve. Although, it is ultimately up to the caregiver's to administer care that comports with the standard of care, it is incumbent upon the families of patients to speak up when they see something to indicate their loved one is being neglected in a nursing home.
