Bed/Pressure Sores

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This is a very painful topic for me as pressure sores was the very worst thing I had to deal with in HD. Even with the best of care and treatment, they can become horrendous for someone who is bedridden and not getting proper nutrition. Anyone's body will eventually breakdown if intervention and action isn't immediately taken. Even then, I was told, sometimes the best they can do is to keep the wound from further breaking down.

If your loved one's skin is starting to breakdown, please demand that their primary care physician or Hospice get a wound care specialist involved right away! And don't let them get away with just sending someone just once!! Nurses are good but they are not up to date on the current treatment for pressure ulcers. It wasn't until I practically had a nervous breakdown, and someone from the list suggested a wound care specialist, that I finally got hospice to have our doctor recommend one.

Be there when the specialist comes. They will examine the wounds and give the nurses instructions, indicating when the wound should be relooked, how often, etc. When this was said to us I said "so, you'll be back March xx right?" They all looked at each other and the specialist said she was only approved for one visit. I then asked "why, because Kelly has a terminal illness? If it were any other patient would you be involved in their care?" and she answered yes. I then told our hospice to get the doctor's to approve her coming on a regular basis, based on suggestions on what was considered "normal" intervention or I wanted Kelly hospitalized in a wound care facility where she would get the treatment she needed. The wound care nurse was approved. You have got to INSIST on them being approved to continue monitoring the wound.

Since Kelly died there are some new wound care products that have hit the industry. This will probably be one of the most critical care things you can do for anyone in late stage Huntington's Disease besides nutrition. Please INSIST on the best wound care they have available.

Jean
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Bed Sores
"What are bed sores and can I do anything to prevent them?"

When you are very sick, you are prone to have skin breakdown wherever the weight of your body presses into the bed. You are at greatest risk if you move very little or you are in bed or in a chair for a long time, especially if you also have been losing weight. Ordinary pressure on the skin as you sit or move across sheets may be enough to tear or breakdown your skin. It is worth a great deal of effort to keep skin well-protected; skin breakdown is uncomfortable, a major indignity, and costly.

Protecting Your Skin

Change position at least every two hours. If you are in bed and comfortable in most positions, it is good to lie on one side, then your back, then the other side. Have a skilled nurse show your family members how to help you shift positions comfortably.

Use pillows to protect the common pressure points, which are under the heels and elbows and between the knees.
(NOTE: The skin care specialists advised us that the use of pillows or like devices are good before any skin breakdown HOWEVER once the skin has started to break down these can cause further damage as the pillow itself can apply pressure from the weight of the body part you are trying to protect/Jean.)

Apply gentle massage with moisturizing lotion or cream to the back, arms, ears, hands, legs, and feet.

If you are at great risk for skin breakdown, you may want to get a special "flotation" bed, which can be rented for home use.

If you or your family notices reddened or broken skin on pressure points, call your doctor or nurse immediately. You may need special medications, dressings, or bed accessories (such as soft pads or heel protectors) to provide added skin protection.

OTHER RESOURCES

Family Practice Notebook http://www.fpnotebook.com

MANAGEMENT OF WOUND-Decubitus Ulcer Prevention

Management: Tissue loads while supine

Positioning in bed
1. Avoid positioning patient on ulcer
2. Use positioning device to keep ulcer off surface
3. Avoid donut-type devices (may cause ulcers)
4. Written repositioning schedules every 2 hours
Prevention for patients at risk
1. Avoid positioning immobile patients on trochanters
2. Use pillows and foam wedges
  1. Relieve heel pressure
  2. Relieve bony prominence pressure (knee and ankle)
  3. Sheepskin does not relieve pressure
3. Maintain head of bed at lowest appropriate level
  1. Limit time head of bed is elevated
  2. Higher head of bed causes patient to slide down
    1. Sliding leads to shear forces
    2. Sacral ulcers may result

Management: Bed Types

Static Surfaces

Surface types
Mattress
Foam
Static floatation
Indications
1. Patient in many positions without loading ulcer
2. No bottoming out of patient
3. Fully compresses surface to <1" at injury site
Dynamic Surfaces
1. Surface types
  1. Air-fluid (costs $100 per day)
  2. Low-air (costs $65 per day)
  3. Alternate air
2. Indications for all dynamic surfaces
  1. Stage 3 or 4 Decubitus Ulcers
  2. Conditions not met for static surface bed
  3. Pressure Ulcer not healing by 2 to 4 weeks
3. Additional indications for air-fluid or low-air bed
  1. Large Stage 3 to 4 Ulcers
  2. Ulcers on multiple turning surfaces
  3. Ulcer fails to heal on dynamic overlay

Management: Tissue loads while sitting
Avoid pressure on ulcer while sitting
Properly position
1. Consider patient weight
2. Consider balance
3. Consider patient stability
Reposition so pressure points shifted once per hour
1. Return to bed if this schedule can not be met
2. Attempt to teach patient to shift weight every 15 min
Appropriate seat cushion (avoid donut-types)

See

Ulcer Grading ; Wound culture not indicated; Decubitus Ulcer Cleansing; Wound Dressing ; Nutrition in Wound Healing and Do not use Incontinence briefs (impedes airflow)

Complications

Cellulitis (bacterial superinfection) or sepsis

Stage 2-5 pressure ulcers colonized with bacteria
Adequate cleansing and debridement prevents infection

Osteomyelitis

Suspect if non-healing ulcer after 2 to 4 weeks

Pharmacology

Local Skin Anesthesia

Digital Block

Mepivacaine

EMLA cream

Lidocaine-Epinephrine-Tetracaine

Xylocaine

Bupivicaine

Wound Dressing

Odor Reducing Dressing

Saline Gauze Dressing

Impregnated Gauze Dressing

Absorption Dressing

Nonadherant Dressing

Hydrocolloid Dressing

Transparent Film Dressing

Dexon

Maxon

Polydioxanone Suture

Vicryl

Nonabsorbable Suture

Braided Polyester Suture

Prolene