Decubitus ulcers, also known as bed sores, are very painful skin wounds that result from remaining in one position too long and the resultant pressure build up caused by this lack of movement. The ulcers range from stage I, characterized by red, non-blanching skin, to stage IV in which the wound may be down to the bone. When the beginnings of the disorder become apparent, the first step of decubitus ulcer treatment is to remove the pressure from the affected area. The wound should then be debrided, i.e., the removal of all of the dead tissue, and cleaned and dressed with a moist protective padding. It should be kept free of urine or feces contamination and changed regularly. To promote healing, the patient may be moved to an egg-crate mattress, air-fluidized bed, or another type of recliner that keeps pressure off of any one part of the body.
After the sore is relieved of pressure, the dead and/or infected skin is debrided. This may be done surgically with hydrotherapy, wound irrigation, or enzymatically. Surgical skin removal, or sharp debridement, is the procedure of choice for an ulcer that has a great deal of necrotic tissue. Hydrotherapy and wound irrigation may be used in conjunction with other types of debridement. Enzymes such as collagenase, or those delivered through the wound fluid, may also be used to debride the wound. This enzymatic debridement is a very slow process and is seldom used with infected wounds.
Once the necrotic tissue has been removed, the next step in decubitus ulcer treatment is staging the severity of the sore. A decubitus ulcer is classified from stage I to stage IV. The skin is not broken in a stage I, but the sore does have non-blanchable erythema, or a red spot on the skin that does not turn white when pressure is applied. Stage II is characterized by an abrasion or blister on the skin's surface. By the time a decubitus ulcer has reached stage III, all skin layers are damaged down to the level of the fascia, or the connective membrane that sits on the muscle. Stage IV has full-thickness skin destruction, tissue necrosis through the fascia, and may include the muscle, bone, tendon, or joint capsules.
Following staging, the wound is covered with a wet-to-dry dressing. A wet bandage or pad is put onto the wound and covered by a dry bandage. The wet bandage dries out over time; when the dressing is changed, the tissues in the wound sticks to the pad when it is removed. Noninfected stage II or III decubitus ulcer treatment may use hydrocolloids, a type of enzymatic debridement, as the wet dressing. Saline-soaked gauze may be used for stages II-IV. Each time the dressing is changed, the wound should be irrigated; occasionally the patient will have whirlpool hydrotherapy before clean dressing is applied.
As part of decubitus ulcer treatment, the patient with stage I or II bed sores may be moved from a regular mattress to an air or water mattress with a foam overlay. An alternating air mattress, low-air-loss, or air-fluidized bed are useful for patients with several decubitus ulcers or ulcers that are not healing well. Patients with large stage III or IV ulcers may be provided with the latter types of beds as well.
Decubitus ulcers are preventable. To avoid additional ulcers and to help the healing, it is essential that the patient be turned every two hours. The patient should not be placed in a position that puts pressure on existing wounds.
Patients whose stage III or IV wounds are not healing may be seen by a plastic surgeon. The surgeon can determine if surgical closure of the bed sore is a necessary part of decubitus ulcer treatment. Surgery will be scheduled for the patient if the surgeon thinks that it will speed healing of the bed sores.
