Tag: wound care

Hospital bed with medical equipment and patient repositioning guide on wall

What is a Pressure Ulcer (AKA Pressure sore)?

On By Dr. Scott RennieIn Skin & Wound Care1 Comment
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bed-sores

Photo credit: http://diseasespictures.com/bedsores/

A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months. He’s diabetic and has lost feeling in the bottom of his feet. He’s had these pressure sores in the past but has trouble getting them to heal up.

Pressure sore: An area of skin damaged by pressure, such as sitting or lying in one position for a long period. They are also called bedsores. They are most common where bone sits near the surface of the skin: the hips, elbows, ankles, and back or buttocks. The skin and soft tissue become damaged because not enough oxygenated blood reaches the area to support healing, usually because the soft tissue is compressed between the surface and the hard bone beneath.

Appearance: The sores change in appearance depending on how long they have been present and how much damage has been done. At the start, the sore looks like a small red patch of skin. If it is not treated, the skin breaks down and a hole or crater forms, which is what we call an ulcer.

Stage 1: The skin is intact without ulceration, but when you press on it the color does not change the way it should. Healthy tissue is pink, and pressing on it with a finger blanches it, with the pinkness returning within a couple of seconds. That does not happen in damaged skin at this stage, and the area may look darkly pigmented.

Stage 2: There is an open, shallow ulcer with a red-pink base. Blisters may be present, either intact or ruptured.

Stage 3: Structures beneath the skin such as fat may be exposed, but at this stage you should not see bone, tendon or muscle.

Stage 4: Bone, tendon and muscle may be visible in the base of the ulcer.

People at risk: Some patients are far more likely than others to develop pressure sores.

  1. Patients who cannot move well because of a medical problem. They may sit or lie in one position for a long time and need help repositioning so the skin does not break down.
  2. Older people, who often move less and whose skin is thinner and more fragile.
  3. Patients with diabetes or nerve problems in their feet, who may not feel a pebble in a shoe or pressure building against the foot.
  4. Patients in the hospital or a nursing home, who are at especially high risk because several of these factors stack: increased age, reduced mobility, and other complicated medical problems.

Prevention: Several things lower the chance of developing pressure sores.

  1. Repositioning the patient’s body every two hours so no one area of skin stays crushed, pinched or under pressure.
  2. Putting pillows between the ankles and knees to reduce pressure on the skin over those bony areas.
  3. Raising the head of the bed when the patient is lying on their side to reduce pressure on the hip bone.
  4. Using special foam or soft mattresses that reduce pressure over the areas that bear the most load.

For patients in wheelchairs:

  1. Use a cushioned seat if possible to prevent pressure on the sacrum.
  2. Tilt forward or to the side every hour to release pressure on the seat.
  3. If the ankles or heels press against the chair, use foam padding to protect against sores.
  4. Check the skin regularly for signs of pressure or ulceration.

Treatment: Pressure sores are treated differently depending on the stage and how severe the skin damage is.

  1. If there is mild erythema, treatment is generally offloading the area by reducing the time it spends compressed, through repositioning and pillows to cushion it. We also use transparent films over the ulcers to protect them.
  2. In patients with diabetes, keeping blood sugars under good control is very important. Elevated blood sugars impede wound healing.
  3. If there is dead or dying skin or soft tissue, it often needs to be removed to help prevent infection.
  4. Special bandages may be needed to keep the healing tissue moist while preventing maceration from being too moist. The dressings we use can be expensive.
  5. Antibiotics may be prescribed if there is a wound infection.
  6. Medication for pain may also be prescribed.

There are scoring tools to grade pressure and track healing. These help for patients who return for repeat visits to a wound care clinic or their primary care provider and need their progress graded. Clinical features examined include:

  1. Amount of exudate
  2. Skin color surrounding the wound
  3. Peripheral tissue swelling
  4. Peripheral tissue firmness around the wound
  5. Amount of granulation (healing) tissue
  6. How much epithelialization is present

It’s important to optimize the nutritional status of patients with wounds. Patients with stage 3 and stage 4 ulcers in particular need enough protein and calories to heal.

Scott Rennie, D.O.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Blog: https://doctorrennie.wordpress.com

Red first aid kit with assorted bandages, scissors, gloves, thermometer, antiseptic, and medication arranged on white surface

Basic Wound Care Tips for Non-Medical Professionals

On By Dr. Scott RennieIn Skin & Wound Care1 Comment
shutterstock_43127152I find that many patients who come into the clinic with a wound have questions about how to take care of it.  The wound might be a post-surgical incision or even a minor cut.  Hopefully this will help with some of those questions. Do I need stitches?:  The best way to know for sure is to be examined by a medical provider, but some basic things we look at: 1)   Depth of the skin wound – if it does not go all the way through the skin, it usually doesn’t need stiches 2)   The size of the wound, whether it’s wide, or jagged.  If it’s large, wide or jagged – there is a higher likelihood of needing stiches 3)   Where on the body the wound is – in areas of the body with lots of stress on the wound, the stitches help hold the skin together better than tape, or a butterfly bandage. 4)   How long ago the injury occurred:  If you got cut 5 days ago, there is less chance sutures would be appropriate because wound healing has already begun. 5)   If it was an animal bite or dirty wound:  We will sometimes put stitches in a wound that was created by an animal bite, but these are generally dirty wounds and we are very careful not to bring the skin together too tight so that the wound can drain. What to do at home – basic guidelines: 1)   Clean the cut or scrape with soap and water.  If there is a piece of glass, or foreign object in the wound that will not come out, you will need to see a medical provider 2)   Stop the bleeding with direct pressure on the wound.  Press a clean cloth or bandage on the wound for 20 minutes minimum without releasing.  If the bleeding is not stopping, contact a medical provider. 3)   Put a thin layer of antibiotic ointment on the wound edges – not in the wound.  I recommend bacitracin (mupirocin) and not Neosporin. 4)   Cover the wound with bandage/gauze to keep the wound clean and dry.  Change the bandage 1-2 times every day until the wound heals 5)   Examine the wound for signs of infection – see below.  Healing time for most wounds is 7-10 days but this can vary. When to see a medical provider: 1)   The wound is deep and/or you can see fatty tissue, muscle, bone or dirty/debris within the wound 2)   You are having severe pain 3)   There are signs of infection (usually begin on about 2-4 days after the wound injury) such as:  Fever, redness, swelling, increased warmth around the wound, pus draining from the wound or red streaks on the skin around the wound. 4)   The wound is from a bite 5)   The wound is a puncture wound caused when a sharp object goes through the skin into the tissue underneath.  There is a higher chance of infection with these kinds of wounds. Do I need a tetanus shot?:  You may need a tetanus booster depending on when your last one was.  If you have deep wound, it is best to contact a medical provider if you’re unsure of whether you need a tetanus vaccine. Abscess:  An abscess is an infection under the skin where bacteria (pus) collect.  A surgical procedure called an I&D (incision and drainage) can be done to drain the pus and heal the infection. If you’ve had an incision and drainage done at your doctor’s office:  After having a surgical procedure done at your doctors office, the wound is often packed with sterile gauze to allow the wound to heal from the bottom upwards.  This way, the wound doesn’t close up at the top and leave a space underneath the top of the skin where bacteria can start growing and cause an infection.  This type of wound needs special attention and observation each day. Basics of wound care after an I&D (incision and drainage): 1)   Keep the bandage/wound clean and dry. 2)   Only remove the bandage to clean around the wound and follow the advice of your medical provider on how to do this. 3)   The packing gauze should be removed little by little until the wound heals completely.  The decision on how much to remove (if any) should be made by a medical provider but this can be explained to the patient on an individual basis (ie. Wounds heal differently depending on the situation). 4)   You may need to wear a splint to decrease movement to the area and allow wound healing. 5)   Antibiotics and pain medication may be prescribed.   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.