Risk factors for pressure sores. The main causes of pressure ulcers in patients

Factors leading to the formation of bedsores can vary. This problem is especially relevant for bedridden patients and those who cannot move independently. Specific causes and places of possible localization were considered. Based on this, brief recommendations were made.

At what stage do bedsores begin to form? What characteristic features can be identified? Answers to these and more questions can be found below.

Bedsores or ulcers appear from constant pressure on certain areas of the skin. It begins to gradually deteriorate and deform. Both muscle and bone structures are prone to negative changes.

Such damage begins to form due to prolonged squeezing and overvoltage. As a result, ischemia begins to develop - a condition characterized by a deterioration in blood flow.

If ischemia lasts more than 2 hours, then tissue necrosis begins, that is, their death. The affected area begins to degenerate exponentially. This process is the "engine" of the resulting bedsores, since they form quickly, this must be monitored.

The degree of damage can vary from a persistent form of erythema to necrosis itself, which begins to cover the skin, individual muscle groups, tendons and bones. Where pressure ulcers form may depend on the current position the patient is in.

If he is in a lying position (on his back) for a long time, then heels, sacrum, elbows, back of the head and shoulder blades are at risk. If he sits, then the places of formation of bedsores may change. For example, feet, shoulder blades and ischial tubercles.

Factors that lead to the formation of unwanted bedsores have been identified: excessive pressure, increased friction, and shearing force.

The pressure rises under the influence of the mass of one's own body. The tissues begin to compress, and the diameter of the vessels begins to decrease. The result of such a process may be ischemia - tissues begin to receive less nutrients.

Excessive pressure may be aggravated by the action of bed linen, tight bandages and dressings.

Displacement force is a process that characterizes the destruction and damage of tissue under indirect pressure. The reason for this phenomenon may be the displacement of the entire bearing surface. A decrease in microcirculation begins in certain corners and the tissues gradually begin to die. The displacement of the tissue can occur at a time when the patient "moves out" from the bed or, on the contrary, reaches for the headboard.

The next stage of formation should be considered the influence of the last component - friction, which can enhance the detachment of the outer layer of the skin and lead to the manifestation of the affected areas.

Friction begins to increase when the skin is moist. This condition is observed in patients suffering from urinary incontinence, increased sweating and dressed in linen that does not absorb moisture well.

The first sign that signals the beginning of the development of bedsores is hyperemia. This process helps the doctor identify areas of the skin that are most prone to pressure sores.

The main stages of the formation of bedsores

Symptoms of the disease can progress rapidly and worsen over time. modern medicine identifies 4 main stages of education, each of them has a number of characteristic features:

The stage passes without damage skin. Separate areas of the skin begin to become covered with erymatous scales that have a red color. The affected area has a distinct pain syndrome, the place itself is hot. In patients with dark skin, it may take a long time for the problem to be detected.
The stage may be characterized by primary trauma to the dermis. It is possible to diagnose the presence of pinkish wounds and individual non-viable tissues, which over time may acquire a yellowish tint.
The stage at which they begin total loss skin in separate areas, the appearance of a deep wound with a deepening. This may affect the subcutaneous fat. Muscles and tendons are weakly palpable. The depth of the recess may vary. In addition, tissue around the affected area may be damaged.
The final stage in which a deep lesion can be diagnosed that can reach the bone. Muscles begin to be exposed and bones become visible. The wound crater is covered with a dark crust, which consists of necrotic tissues. Depth may vary. Everything will depend on the current location of the lesion and the overall thickness of the skin.

In order to assess the current condition of the patient, it is sometimes necessary to first clean the crater from the scab. If the pressure sore looks dark red or brown spot, then we can talk about the deep degree of damage.

It is better to prevent the problem at the stage of its inception. Knowing the main steps described above, you can minimize the potential risk of developing a problem.

Literature:

1. Krutko D.T., Popova E.V. n etc. "Technique for performing therapeutic and diagnostic manipulations and procedures in therapy", Mn. 2008

2. Matveev V.F. "Fundamentals of medical psychology, ethics and deontology", M. 1984

3. Murashko A.M. "General nursing", M. "Medicine", 1988

The development of bedsores on the body complicates the treatment of patients in the wards intensive care, geriatric departments, as well as during the rehabilitation period at home, after, with spinal, complex, spinal injuries, coma, other pathologies, with a forced presence of a person in a monotonous position.

What are bedsores?

- this is a pathological change in the skin, subcutaneous tissue, muscles, bones, and other tissues of the body, developing as a neurotrophic disorder, the causes of which are a violation of innervation, blood and lymph circulation of a local area of the body, with prolonged contact with a hard surface.

Brief description of pathological changes on the body:

develop on the side of the body adjacent to a hard surface;

are characterized by staging of pathogenesis, begin with circulatory stasis, in the absence of treatment, end with neurotrophic wet or dry type, sepsis or gas gangrene;

most rapidly, within a day, develop in malnourished patients, with congestion in cardiovascular insufficiency;

localized on protruding areas of the body, the most typical lesions:

when the patient is positioned on the back, the area is affected (sacrum and coccyx, buttocks, spinous processes of the spine, area of the shoulder blades, heels);

when the patient is on his stomach, the area is affected (knee, ridges ilium, bulging surface of the chest);

when the patient is positioned on his side or half-sitting, the area (sciatic tubercles) is affected;

rarely localized on the back of the head and folds of the mammary glands.

Specific localization of bedsores on the skin: under plaster bandages, in places of tight fit of materials that do not penetrate moisture (oilcloth diapers, rubber tubes), folds of bed linen, bandages, etc.

Specific localization of bedsores on the mucous membranes: under dentures, with prolonged drainage of the urethra - on the urethra, with prolonged catheterization of blood vessels - on the vascular mucosa.

Bedsores rarely develop in young people who are conscious, without an anamnesis, aggravated chronic diseases. Usually, in this category of patients, if there are bedsores, they develop gradually, there is a high probability of missing an impending pathology.

The first signs of bedsores

Subjective sensations that the patient can report to caregivers, while being conscious and preserved pain sensitivity parts of the body:

tingling on the skin in places where pressure sores are likely to develop, is associated with stagnation of biological fluids (blood, lymph) that feed the nerve endings;

loss of sensation (numbness), after about 2-3 hours in this area of the body.

Visible signs of an incipient bedsore that caregivers must know:

stagnation of peripheral blood and lymph, initially in the form of a venous bluish-red color, without clear boundaries, with localization at the point of contact of the bone, muscle protrusions of the body with the bed, the intensity of skin staining: from barely noticeable to saturated;

desquamation of the epidermis of the skin with the preliminary formation of purulent vesicles or without them.

These are signs of an incipient pressure sore. It is urgent to take measures to prevent further aggravation of the pathology.

What to do to eliminate the first symptoms of a bedsore?

For this you need:

change the position of the patient every two hours, if there are no contraindications, it is recommended to use special pillows to change the position of the limbs and body relative to the surface of the bed, forming gaps between the skin and the bed;

monitor the level of the patient's headboard, the headboard should be lower or flush with it;

regulate the moisture content of the patient's skin with hygiene products (washing cream, foam, solution, spray, you can warm baths (it is forbidden to use hot water), do these procedures twice a day, with uncontrolled defecation, remove contaminants as quickly as possible;

remove excess moisture from the skin and skin folds(water, liquid food residues, urine, wound exudate, sweat) using special absorbent pads, diapers, wipes, towels, films;

regularly re-lay the bed or change bed linen at least once a day;

do not do an intense massage, light stroking of skin areas with signs of stagnation is allowed, carry out this procedure carefully, without friction, especially in areas with close bones;

use anti-decubitus mattresses of a balloon or cellular type, equipped with special silent compressors to maintain and change the rigidity of its base, with adjustable and programmable inflation of different areas.

use, for patients in wheelchairs, pillows filled with gel foam, air, monitor the change in body position in the chair at least once an hour.

Why are pressure sores dangerous?

Bedsores are pathologies, the treatment of which is best avoided. If this could not be done, then with the formation of foci of skin maceration, the pathogenesis develops very quickly, with the formation of foci of tissue necrosis and is characterized by long-term treatment of a purulent wound. Dangerous outcomes of bedsores. In some cases, bedsores are the cause of:

extensive excisions of soft tissues and the formation of defects with impaired innervation and blood circulation of the underlying parts of the body,

amputations lower extremities;

necrotic lesions of the periosteum and bone tissue in the form of periostitis;

depletion of the body's defenses, complicating the treatment of the underlying disease;

With the development of bedsores by the type of dry necrosis, a protracted pathogenesis develops with long periods of defect healing.

The reason for the bedsores is as follows. Our body is full of small blood vessels. Through these vessels - capillaries - blood flows to various organs of the body. If the blood vessels are squeezed, then the blood stops flowing to the tissues, as a result of which the tissues become dead.

If a person is immobile for two hours, his blood vessels are compressed and the blood stops flowing to certain parts of the body tissues. Therefore, bedsores are formed. Remember that it is very dangerous to sit or lie still for a long time.

Also, pressure sores are formed if a wet sheet is often pulled out from under a sick person. When this happens, the blood vessels rupture. It is completely invisible to the human eye. But after the rupture of blood vessels, blood stops flowing to the tissues. Bedsores are formed.

Also, blood vessels can break if a person cannot, for example, walk and constantly slides himself to take a different position.

Risk Factors for Pressure Sores

It is noticed that bedsores develop in bedridden patients at different times. AT medical institutions, to systematize the assessment of risk factors for the development of bedsores, the Norton, Braden or Waterlow scales are used. At home, they do not matter. On the basis of these criteria, risk factors associated with care errors and individual characteristics patient suitable for home use.

1. Factors associated with errors in the organization of patient care:

untidy bed, re-made less than once a day;

rare change of underwear to dry and clean;

neglect hygiene procedures(treatment of the body with special solutions, drying, massage of body parts where possible without additional trauma to the bedsore);

hard, uneven bed surface.

2. Factors associated with the individual characteristics of the patient's condition:

elderly age;

exhaustion or vice versa obesity of the patient;

diseases of cardio-vascular system;

diseases associated with impaired innervation of the body (including strokes);

disorders associated with changes in metabolic processes in the body (, violation of water-salt metabolism or the usual restriction in drinking);

unbalanced nutrition or lack of protein food in the diet, protein dystrophies (protein metabolism disorders);

the patient's condition (coma, dementia, other) in which he does not control defecation, urination.

In addition, the factors provoking the occurrence of bedsores include smoking, diabetes, lack of water and little nutrition, excess or, on the contrary, very small weight, urinary and fecal incontinence, dirty skin, crumbs and small objects in bed, allergic reaction on skin care products, folds, seams, buttons on underwear, as well as injuries and diseases of the spinal cord and brain, sweating during.

Stages and degrees of bedsores

The pathogenesis of bedsores is characterized by stages of development. There are four stages of pathogenesis.

I stage bedsores

Visually determined by venous erythema at the site of skin contact with a foreign surface. Venous erythema is the result of obstructed outflow of blood from a local area.

How to distinguish venous erythema from arterial hyperemia and bruising?

Difference from arterial hyperemia:

the color of venous erythema is red-cyanotic, the color of arterial erythema is bright red;

the local temperature of venous erythema corresponds to the temperature of the skin or slightly lower, the local temperature of arterial hyperemia is a warm area of the skin at the place where the temperature is determined.

Difference from a bruise:

red-bluish color of the skin in the place of pressure of the finger does not change (bruising)

a similar color of the skin at the site of pressure turns pale (venous hyperemia).

Venous hyperemia (erythema) of protruding bone areas of the human body adjacent to foreign surfaces, without violating the integrity of the skin - the most important feature decubitus of the first stage.

Stage II bedsores

Visually determined by the thinning of the epidermis - the upper layer of the skin, followed by peeling, the formation of bubbles. The pathogenesis develops as follows: venous congestion provokes tissue malnutrition, innervation of a body area, excess fluid in the skin, causes swelling (maceration) and rupture of epidermal cells.

Superficial skin lesions in the form of thinning and peeling of the epidermis, integrity violations, maceration (moisturizing) are the most important sign of the second stage of the bedsore.

Stage III bedsores

Visually defined as a wound with suppuration (contamination with microflora) or without suppuration.

Involvement in the pathogenesis of deep layers of skin tissues, subcutaneous tissue, muscles with a purulent type of inflammation and incipient processes of necrosis (tissue death) are the most important sign of the third stage of pressure sores.

Stage IV bedsores

It is visually defined as a local cavity or a defect formed as a result of decay (necrosis), along the edges of the cavity is filled with defect walls on which purulent inflammation continues.

A necrotic cavity and its expansion due to inflammation of the walls is the most important sign of the fourth stage of a bedsore.

On different parts of the body, there may be different stages bedsores.

Suppuration of the area of the bedsore begins from the second stage, develops in the third and fourth, after the seeding of the wound with streptococci, other pyogenic microorganisms of the area.

A common path for the development of a purulent bedsore is erysipelas and phlegmon. In severe cases, the bedsore turns into sepsis or gas gangrene.

1. The development of purulent bedsores by the type of erysipelas

suppress microbial contamination of the wound.

Revision of the wound, cleaning the edges of necrotic tissues is performed in the conditions of the surgical department. For the outflow of pus, drainage tubes are made and they are regularly inspected.

Passive drainage can be carried out at home:

To do this, the wound is filled with special napkins, impregnated with compounds that promote the outflow of pus. Change napkins periodically. As napkins, you can use ordinary bandages, the edges of which do not fall apart into threads. Solutions and ointments are used to impregnate napkins.

Outdated medicines: hypertonic solutions 10% sodium chloride, 3-5% boric acid solution and others. At present, the use of such solutions is limited due to the low suction power of 4 to 8 hours.

Hydrophobic ointments (liniments, emulsions) on a vaseline basis (liniment according to Vishnevsky, synthomycin emulsion, tetracycline, neomycin and others). Their disadvantage is that they do not absorb pus, the antibiotics in their composition do not work in full force.

Modern medicines: hydrophilic (water-soluble ointments) - Levomekol, Levosin and other water-soluble formulations. They well remove pus from the wound, for about 20-24 hours. Attention! Use hydrophilic ointments only if there is pus in the wound; in another situation (no pus), these ointments are not effective.

Enzyme therapy is the next method of surgical treatment of purulent wounds (therapy with pus-removing enzymes).

Proteolytic enzymes (trypsin, chymotrypsin, others). To enhance their action, a combination of these or other enzymes with ointments is used, for example, a combination of enzymes and Iruksol ointment.

Antiseptic solutions for external use. furatsilin, hydrogen peroxide, boric acid (currently used to a limited extent). Modern formulations are shown for use - 0.5% iodopyrone solution, 1% dioxidine solution.

Physical methods of treatment. Traditional methods are used (UHF, ultrasonic cavitation, oxygenation, vibrophoning, laser therapy and other similar methods)

II. In the second phase

In the second phase, after cleaning the bedsore from pus, the appearance of healthy tissues is achieved. A healthy scab is a thin layer of dried granulations. A purulent scab is a thick crust of dried pus. Recovery under a purulent scab is impossible!

When healthy granulations appear, treatment is prescribed:

relieving inflammation;

protecting healthy granulations (healthy tissues) from accidental damage;

stimulating tissue repair processes.

To relieve inflammation use:

ointments (hydrophobic ointments - methyluracil, troxevasin, hydrophilic ointments - bepanten and others);

herbal preparations- juice, oil ( , );

laser therapy with therapeutic effect stimulation of tissue epithelialization.

III. Into the third phase

In the third phase, regeneration and scarring of the wound process are achieved. use modern drugs stimulating epithelialization and scarring of tissues, for example: EDAS-201M, vitamins, immunostimulants. At all phases of pathogenesis, the use of antibacterial agents is allowed, intravenous drip administration of a metrogil solution, antibiotics is recommended.

The resulting defects and the consequences of bedsores are treated in a hospital.

Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma of educational and scientific medical center Administration of the President of the Russian Federation.

Any seriously ill patient is affected by numerous risk factors for pressure sores.

Decubitus (from lat. decubare - to lie) - a pressure ulcer that occurs in certain parts of the body and under certain conditions.

A bedsore occurs as a result of a local lack of blood supply (ischemia) and the resulting cell death (necrosis).

Internal risk factors for pressure sores

External risk factors for the development of bedsores

Skin care

Scheme of examination of the skin: Examine and feel the skin.

Theoretical justification:

Skin aging affects the state of the protective barrier, reduces the perception of pain, properties immune system slows down the wound healing process.
Dry skin is more prone to injury.
Cracks contribute to the penetration of microorganisms deep into the tissues

Places of localization of bedsores

In the “on the back” position, bedsores develop in the back of the head, shoulder blades, elbows, sacrum, ischial tuberosities, and heels. In the position "on the side" - in the area auricle, shoulder, elbow joints, hip, knee, ankle. In the "sitting" position - in the area of the shoulder blades, sacrum, heels, toes.

Decubitus Treatment Scheme

Initial assessment of the overall situation:

Place of formation of the bedsore, severity, general condition of the wound.
Assessment of the patient's status.

By the presence or absence of pressure sores, one can judge the quality of patient care.

The main measures aimed at the prevention of bedsores:

1. Decrease in pressure when the patient is sitting or lying down. To do this, it is necessary to change the position of the patient's body every 2 hours, turning by 30 degrees.

2. The use of special mattresses, bedding.

3. Activation of blood circulation:

daily skin massage using special products (skin oil, tonic liquid, body lotion);
stabilization of blood circulation due to the change of active and passive movements, clothing should be spacious.

4. Skin protection:

daily washing or rubbing of the skin using pH-neutral skin washes;
the use of clean, wrinkle-free bed and underwear;
the use of diapers, pads with a gel-forming substance for incontinence;
the amount of liquid consumed should be at least 1.5-2 liters. (if there are no contraindications). Restriction of fluid intake leads to irritation Bladder. The concentration of urine increases and may increase urinary incontinence.

With age, the skin becomes thinner, the activity of sweat and sebaceous glands, the protective functions of the skin are reduced. Ordinary detergents for skin care have an alkaline environment, destroy the hydrolipidic layer and shift the acid balance pH 9.0 - 14.0, which significantly worsens the skin condition. Bed rest, urinary and fecal incontinence adversely affect the condition of the skin and weaken its ability to recover.

Professional skin care, the use of disposable hygiene products, the correct position of the patient in bed contribute to the prevention of pressure sores.

Pressure sores (decubitus - decubital ulcer) are chronic soft tissue ulcers that occur in patients with impaired sensitivity (usually immobile) due to pressure, friction or displacement of the skin, or as a result of a combination of these factors.

ICD-10 code

L89. bedsores

ICD-10 code

Epidemiology

The incidence of bedsores in hospitalized patients ranges from 2.7 to 29%, reaching 40-60% in patients with spinal cord injury. In health care facilities in England, bedsores occur in 15-20% of patients. The organization of high-quality care, which is carried out by specially trained nurses, can reduce the incidence of this complication to 8%.

Treatment of patients with bedsores is a serious medical and social problem. With the development of pressure ulcers, the duration of the patient's hospitalization increases, there is a need for additional dressings and medicines ah, the tools, the equipment. In some cases it is required surgery bedsores. The estimated cost of treating pressure ulcers for a single patient in the United States is between $5,000 and $40,000. In the UK, the cost of caring for patients with bedsores is estimated at £200 million and is rising by 11% annually.

In addition to the economic costs associated with the treatment of bedsores, it is necessary to take into account non-material costs: severe physical and moral suffering experienced by the patient. The occurrence of bedsores is often accompanied by severe pain, depression, infectious complications (abscess, purulent arthritis, osteomyelitis, sepsis). The development of bedsores is accompanied by a consistently high mortality rate. Thus, the mortality rate in patients admitted to nursing homes with bedsores, according to various sources, ranges from 21 to 88%.

Why do bedsores occur?

Most often, bedsores are found in long-term immobilized patients who are in a forced position after an injury, with oncological and neurological pathologies, in elderly and senile patients with severe therapeutic diseases, as well as in patients who are treated for a long time in intensive care units and intensive care units.

The main factors leading to the development of bedsores are the forces of pressure, displacement and friction, high humidity. Risk factors include limited motor activity of the patient, malnutrition or obesity, urinary and fecal incontinence, poor care, comorbidities such as diabetes, paralysis, and cancer. A significant risk factor is belonging to the male sex and the age of the patient. In patients older than 70 years, the risk of pressure sores increases dramatically. Of the social factors, it should be noted the lack of service personnel.

Ulcers resulting from bedsores are areas of tissue necrosis that occur in weakened individuals as a result of compression by the body of the soft tissues directly adjacent to the bones and bone protrusions. Prolonged exposure to continuous pressure leads to local tissue ischemia. It has been experimentally and clinically established that a pressure of 70 mmHg applied to tissues continuously for two or more hours leads to irreversible changes in tissues. At the same time, with the periodic action of pressure of even greater force, tissue damage is minimal.

The combined effect of pressure and displacement forces causes blood flow disturbances with the development of irreversible tissue ischemia and subsequent necrosis. Muscle tissue is the most sensitive to ischemia. In the muscles located above the bone protrusions, first of all, develop pathological changes, and only then they spread towards the skin. Accession of infection exacerbates the severity of ischemic tissue damage and contributes to the rapid progression of the necrosis zone. The resulting skin ulcer in most cases is a kind of iceberg tip, while 70% of all necrosis is located under the skin.

Risk Factors for Pressure Sores

One of the main steps in the prevention of bedsores is to identify patients at high risk. Risk factors for developing pressure ulcers can be reversible or irreversible, internal or external. Internal reversible risk factors are malnutrition, limited mobility, anemia, malnutrition, insufficient ascorbic acid intake, dehydration, hypotension, urinary and fecal incontinence, neurological disorders, peripheral circulatory disorders, thin skin, restlessness, confusion, and coma. External reversible risk factors include poor hygienic care, folds in bed and underwear, bed rails, use of patient restraints, injuries of the spine, pelvic bones, organs abdominal cavity, damage spinal cord, the use of cytostatic drugs and glucocorticoid hormones, the wrong technique for moving the patient in bed. To external factors the risk of developing pressure ulcers include extensive surgical intervention lasting more than 2 hours.

Significant assistance in assessing the risk of developing pressure ulcers is provided by various scales. The most widely used scale is J. Waterlow. In immobile patients, the assessment of the risk of developing pressure ulcers is carried out daily, even if at the initial examination it was no more than 9 points. Anti-decubitus measures begin immediately when there is a high risk of their development.

The scores on the J. Waterlow scale are summarized. The degree of risk is determined by the following total values:

no risk - 1-9 points;
there is a risk - 10-14 points;
high risk - 15-19 points;
very high risk - more than 20 points.

Symptoms of bedsores

Localization of bedsores can be extremely diverse. The frequency of identifying the location of pressure ulcers depends on the specialization of the clinic or department. In multidisciplinary hospitals, in the vast majority of patients, bedsores form in the sacrum. Quite often the region of the greater trochanter, heels and ischial tuberosities is affected. In more rare cases, a decubital ulcer occurs in the region of the shoulder blades, lateral surfaces chest, bony protrusions of the spine, extensor surfaces knee joints and on the back of the head. Multiple bedsores occur in 20-25% of cases.

At the beginning of the development of a bedsore, local pallor, cyanosis and swelling of the skin appear. Patients complain of a feeling of numbness and slight soreness. Later, detachment of the epidermis occurs with the formation of blisters filled with cloudy serous-hemorrhagic exudate, necrosis of the skin and deep tissues occurs. Infection exacerbates the severity of necrotic tissue damage.

Clinically, bedsores proceed according to the type of dry or wet necrosis (decubital gangrene). With the development of a bedsore by the type of dry necrosis, the wound looks like a dense necrotic scab with a more or less distinct line of demarcation of non-viable tissues. Due to the weak pain syndrome and unexpressed intoxication, the general condition of the patient does not suffer significantly. Heavier clinical picture observed with the development of bedsores by the type of wet necrosis. The zone of deep irreversible tissue ischemia does not have a clear boundary, it progresses rapidly, spreading not only to subcutaneous tissue but also on fascia, muscles, bone structures. The surrounding tissues are edematous, hyperemic or cyanotic, sharply painful on palpation. From under the necrosis, a foul-smelling, purulent discharge of gray color is plentiful. Symptoms of severe intoxication are noted with a rise in body temperature to 38-39 ° C and above, accompanied by chills, tachycardia, shortness of breath and hypotension. The patient becomes drowsy, apathetic, refuses to eat, delirious. Blood tests reveal leukocytosis, increase in ESR, progressive hypoproteinemia and anemia.

Classification

There are several classifications of decubitus ulcers, but at present the most widely used is the classification of the Agency for Health Care Policy and Research (USA) adopted in 1992, which most clearly reflects the dynamics of local changes in the area of a pressure ulcer:

I degree - erythema that does not spread to healthy areas of the skin; damage preceding ulcer formation;
II degree - partial reduction in skin thickness associated with damage to the epidermis or dermis; superficial ulcer in the form of abrasion, bubble or shallow crater;
III degree - complete loss of skin thickness due to damage or necrosis of tissues located under it, but not deeper than the fascia;
IV degree - complete loss of skin thickness with necrosis or destruction of muscles, bones and other supporting structures (tendons, ligaments, joint capsules).

Classification of bedsores by size:

fistulous form - a small skin defect with a significant deeper cavity; often accompanied by osteomyelitis of the underlying bone;
small bed sore - diameter less than 5 cm;
average bed sore - diameter from 5 to 10 cm;
large bedsore - diameter from 10 to 15 cm;
giant bedsore - diameter more than 15 cm.

According to the mechanism of occurrence, bedsores are distinguished exogenous, endogenous and mixed. Exogenous bedsores develop as a result of prolonged and intense exposure to external mechanical factors leading to ischemia and tissue necrosis (for example, a bedsore as a result of tissue compression with a plaster cast or a pressure sore of the sacrum in a patient who has been in a stationary position for a long time). Elimination of the causes that caused the bedsore usually contributes to the development of reparative processes and its healing. Endogenous bedsores develop due to a violation of the body's vital functions, accompanied by neurotrophic tissue changes as a result of diseases and damage to the central and peripheral nervous system(eg, in patients with spinal injury and stroke). Healing of such bedsores is possible with improvement general condition organism and tissue trophism. Mixed bedsores develop in patients who are weakened and exhausted by a serious illness, alimentary cachexia. The inability to independently change the position of the body as a result of prolonged tissue compression leads to ischemic damage to the skin in the area of bone protrusions and the formation of bedsores.

There are also external and internal bedsores. External bedsores develop in the area of the skin. Internal bedsores occur in various parts of the mucous membranes that are subjected to prolonged compression foreign bodies(drainages, catheters, prostheses and stents) and endogenous formations (calculus of the gallbladder). Internal bedsores can lead to perforation of the organ wall with the development of an internal fistula, peritonitis, phlegmon and other complications.

Complications of bedsores aggravate the condition of patients, worsen the prognosis of the disease, for the most part representing a real threat to the life of the patient, becoming one of the main causes of death of patients. These include:

contact osteomyelitis of the underlying bone;
purulent arthritis and tendinitis;
erosive bleeding;
malignancy;
phlegmon;
sepsis.

Osteomyelitis occurs in almost 20% of patients with bedsores. Most often, the sacrum, bones of the coccyx, ischial tubercle, calcaneus, and occipital bones are affected. The most severe osteoarticular destructive changes occur in patients with decubitus ulcers in the greater trochanter. Osteomyelitis of the greater trochanter develops, and in more severe cases - purulent coxitis, osteomyelitis of the head femur and pelvic bones. Diagnosis is based on visual assessment of the bone, which becomes dull, gray in color, lacks periosteum, is saturated with purulent exudate, becomes brittle on contact, and bleeds little. In case of difficulties in diagnosis, X-ray examination, fistulography, CT and MRI are used. It should be noted that clear radiological data appear in late dates development of osteomyelitis with extensive bone lesions and sequestration.

Phlegmon is the most severe complication of bedsores. It develops in 10% of patients with bedsores, and is the main reason for emergency hospitalization of patients. Phlegmon mainly complicates the course of bedsores, flowing according to the type of wet necrosis. At the same time, a significant deterioration in the condition of patients is noted, symptoms of a systemic inflammatory reaction progress, pain syndrome, signs of organ dysfunction develop. Local changes have a negative trend. Significantly increased peri-focal inflammatory changes. Hyperemia, edema and tissue infiltration spread over a large area; both on the skin around the bedsore, and at a distance from it, cyanotic spots and blisters appear. With a large accumulation of pus, fluctuation can be determined, and with the anaerobic nature of the infection, tissue crepitation appears. Phlegmon usually develops as a result of a delay surgical treatment with the development of wet decubital gangrene. Purulent-necrotic process begins in the deep layers of soft tissues, progresses rapidly and is accompanied by severe destructive changes in tissues with the development of necrotic dermatocellulitis, fasciitis and myonecrosis. In more than 80% of all cases of phlegmon, it occurs in patients with pressure sores of the sacrum. Purulent process can spread to the gluteal and lumbar regions, perineum, back of the thigh. In the vast majority of cases, the purulent-necrotic process is caused by polyvalent microflora. The main role is played by microbial associations consisting of Staphylococcus aureus, Streptococcus spp., Enterococcus spp., bacteria from the genus Enterobacteriaceae, Pseudomonas aeruginosa, anaerobic clostridial and non-clostridial infections. In malnourished debilitated patients of elderly and senile age, the lethality in the event of phlegmon against the background of a bedsore exceeds 70%.

If the lateral surface is subjected to compression, then bedsores occur on the shoulders, elbows, lateral surfaces of the thighs and pelvis.

Factors affecting the formation of bedsores

Bedsores are very dangerous complication in an already seriously ill patient, which worsens the treatment of the underlying disease and requires separate long-term treatment, especially in the last stages.

Phlegmon

Acute inflammation of the cell space is accompanied, treatment is difficult due to the fuzzy border of the inflammatory process. The causative agent is staphylococcus aureus coli. The main symptoms are pain, swelling, redness,. Treatment is carried out by opening the focus and using broad-spectrum antibiotics.

Gangrene

This complication is accompanied by rapid tissue necrosis. On palpation, a specific crunch is heard, the color of the epidermis is predominantly dark, and a putrid odor emanates from the wound. Intramuscular injections of penicillin give a good result, but mainly to avoid damage to neighboring tissues. The affected body part, usually a limb, must be amputated. This complication accompanies, with insufficient or ineffective treatment, bedsores at stage 4 of development.

Sepsis

The fight against this complication is effective only on early stages. Since it is systemic inflammatory process, which affects the weight of the body as a whole, then the further development of the infection leads to death. Detoxification of the body, anti-inflammatory treatment with the use of glucocorticoids is carried out. Septic infection of the body can accompany treatment for 3rd and 4th degrees of bedsores.

Preventive actions

Analyze the history and ensure the maximum exclusion of the causes leading to the formation of pressure sores.
It is enough to use a functional bed for immobile patients, with an anti-decubitus mattress and made of natural fabrics. effective way preventing the development of bedsores.
Activation of the patient - breathing exercises, physiotherapy taking into account the physical capabilities of the patient, .
Constant and correct skin hygiene, especially in places of friction and pressure, using products that do not cause an allergic reaction.
Organization of the daily routine and, taking into account the condition of the patient.
The diet should be optimally balanced in terms of vitamin and mineral composition in order to maximize the proper functioning of organs and systems, without overeating. This is especially important for a bedridden patient, as excess weight interferes with the full process of rehabilitation.
Regular inspection and expert advice.

Bedsores, like any other disease, are easier to prevent than. Moreover, long-term treatment requires costs, both material and moral, especially when home care for bedridden patients.

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