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PREVENTION AND TREATMENT OF CHRONIC WOUNDS

 

Chronic wounds, especially decubitus ulcers (commonly called "bedsores"), are a serious problem not only to the medical society but also to the patients and their families.

Introduction

Decubitus ulcers can develop in hospitalised patients, bedridden patients as well as in those being at home or using wheelchairs.

The group with the highest risk of decubitus ulcers are elderly or unconscious patients as well as diabetics.

 

Definition of a decubitus ulcer

A decubitus ulcer is a damage to the skin and deeper tissues as a result of prolonged or recurrent pressure leading to ischaemia and necrosis. Quite often it can be or is a development place of infection.

 

Etiology

The causes of decubitus ulcers can be divided into:

  • 1. outer factors:
  • pressure, causing ischemic tissue damage and, as a result, necrosis
  • friction, causing the damage of epidermis; the friction appears for example as a result of inappropriate positioning of the patient in bed
  • maceration, causing the damage of epidermis; it can appear for example as a result of urinary and fecal incontinence or hyperhidrosis
  • 2. inner factors:
  • patient's age (especially above 70)
  • chronic diseases: diabetes, metabolic disorders, atheromatosis, peripheral circulation disorders, neoplastic diseases
  • patient's physical state: weight and nutrition state (undernutrition, dehydration, overweight)
  • limitation in mobility
  • psychical state (depression, excitation, coma)

 

Formation place of a decubitus ulcer

A decubitus ulcer may develop in places where the distance between bony prominences and skin surface is the smallest, so in the contact place of the skin with the surface - where the pressure is the highest.

 

Prevention

The best way of prevention is the education of patients and their families. An educated patient is aware of the threats connected with the first symptoms of emerging decubitus ulcers and knows how to react.

In the education it is important to put emphasis on the proper care connected with daily check of the patient's skin for the first symptoms such as:

  • skin redness that continues to exist even after pressure relief
  • blisters appearing in the pressure area
  • damage to the integrity of the skin in the pressure area.

It is extremely important to impress on the caregivers and most of all on the patients themselves how important it is reposition the patient frequently - depending on the skin condition the position should be changed every 30 minutes to maximum 3 hours. The repositioning should be done in a way preventing the patient (as far as possible) from sitting (lying) on an already existing wound.

It is also vital to introduce in home care pressure-reducing mattresses, cushions and underpads.

Moreover, prevention actions should also concern:

  • appropriate diet and hydration - the diet should provide appropriate number of calories and proteins
  • use of natural smooth bedclothes, which ought to be frequently changed in people with hidrosis
  • avoidance of patient's overheating and oversweating
  • high care for appropriate skin greasing
  • application of film dressings, reducing the friction between the bed and the patient's skin.

Basic treatment methods of ulceration

  • surgical debridement - removal of necrotic derbis uncovering healthy structures in order to initiate a wound healing process.
  • traditional wound treatment - deals with the application of absorbent gauze dressings, which absorb the excess of wound exudate but do not provide efficient barrier against the outside infection-causing environment. The traditional dressings dry out the wound bottom, which slows down the healing tempo, makes the dressing change extremely painful and damages newly formed tissue.
  • modern wound treatment - the new treatment method deals with closing the wound by means of a special dressing, which:
  1. maintains the appropriate level of moisture on the wound surface in order to create an optimum healing environment and accelerate a healing process
  2. promotes autolitic cleansing, which results in quicker wound cleansing 
  3. provides termal isolation of the wound, which enables to maintain stable temperature
  4. provides long-term absorption of the excess of wound exudate and so dressing changes are required less frequently
  5. does not stick to the wound, enabling painless change of the dressing
  6. is waterproof and protects the wound against external factors,  minimising the infection risk

Having analysed the situation a physician has to decide which method or combination of methods to apply, or he should consult a specialist.

Main groups of specialist dressings used in the treatment of decubitus ulcers:

  • hydrogel dressings
  • alginate dressings
  • absorbent dressings
  • hydrocolloid dressings
  • film dressings

Hydrogel dressings

  • in form of a gel that when applied into the wound hydrates necrotic tissue enabling its natural autolysis process and cleansing. The hydrogel can also absorb small amounts of wound exudate.

Application: shallow and deep wounds with black necrotic tissue

Exudate level: none or scant

Alginate dressings

  • in form of soft fibres, which absorbing wound exudate change into gel; this facilitates wound cleansing and crates a moist environment. The alginate dressings contain calcium alginate, which has haemostatic properties.

Application: shallow and deep wounds with yellow colliquative necrotic tissue

Exudate level: heavy or moderate

Polymer absorbent dressings

  • in form of soft elastic foam, having the structure of many air cells. In some dressings it is modified by means of heat. The dressings are in form of flat squares. They have high absorption capacity, provide thermal isolation, are air-permeable and maintain a moist environment between the wound and the dressing.

Application: shallow wounds with yellow colliquative necrotic tissue and in granulation stage (tissue formation)

Exudate level: heavy or scant

Hydrocolloid dressings

  • impermeable dressings, which, thanks to their properties, maintain a perfect moist wound healing environment. Having contact with wound exudate the hydrocolloid layer of the dressing increases its volume, forming soft yellowish gel, under which the healing process takes place.

Application: shallow wounds with yellow colliquative necrotic tissue, in granulation stage or in early epithelisation stage

Exudate level: moderate or scant

Dressings with silver

  • having contact with wound exudate silver ions get activated - they have bactericidal properties.

Application: wounds with yellow colliquative necrotic tissue or wounds or in granulation stage, infected or clean

Exudate level: heavy or moderate

 

Film dressings

  • thin transparent elastic polyurethane membrane. Its structure enables free evaporation from the wound surface, yet it is resistant to water and bacteria from outside - protects the wound against contamination and thus against infection. The transparent surface enables observation and supervision of the healing decubitus ulcer.

Application: shallow wounds in epithelisation stage

Exudate level: scant

Choosing an appropriate dressing to the wound

The application schema of particular dressing depending on the wound condition:

   

Black necrosis

  • hydrogel dressings

 

Yellow necrosis

  • alginate dressings - heavy or moderate exudate; surface or deep wounds
  • absorbent dressings - heavy or moderate exudate; surface wounds
  • hydrocolloid dressings - moderate or scant exudate; surface wounds

Exudate phase, growth of granulation tissue

  • alginate dressings - heavy or moderate exudate; surface or deep wounds
  • absorbent dressings - heavy or moderate exudate; surface wounds
  • hydrocolloid dressings - moderate or scant exudate; surface wounds

 

Epithelisation phase

  • hydrocolloid dressings - moderate or scant exudate; surface wounds
  • film dressings - scant exudate; surface wounds

 

Infected wounds

  • dressings with silver - heavy or moderate exudate; surface wounds

 

  Summary

There are different types of decubitus ulcers - they can be shallow or deep, often contain a big amount of necrotic tissue and produce bigger or smaller amounts of exudates. Therefore, there is not only one universal dressing which would find application in any case. The efficient treatment of decubitus ulcers in every stage can be done only thanks to the doctor's knowledge, appropriate choice of the dressing to the processes appearing in the wound and, most of all, consistent work of the patients, their families and medical staff.

MD, PhD Marek Załucki

General surgery specialist

Specialty Hospital Matopat

Non-public Health Care Centre, Toruń