According to conservative estimates, each year in Germany more than 500,000 people develop a decubitus. Already in descriptive histories of ancient Egypt there are indications of treatment done for pressure ulcers on a young princess. She had a fist-sized decubitus in the sacral area, which was supposed to have been “cured” via skin grafts. The transplanted tissue was however rejected and the princess died.
Pressure ulcers as cause of death
Cause of death: decubitus. While this does not end up on the death certificate, in some cases it is the sad reality. The Institute of Forensic Medicine at the University of Hamburg investigated pressure ulcers and pressure sores in a cross-sectional survey of 10,222 deceased persons. The shocking results prompted forensic pathologists in Hannover and Berlin to conduct similar surveys, which led to similar or even more dramatic results. According to these studies it seems certain that some 10 percent of the deceased people had indicators for decubitus due to incorrect care, inadequate wound treatment and malnutrition.
The public’s interest in the decubitus problem was aroused by press reports of care scandals. Decubitus is considered within the healthcare debate to be a quality indicator for nursing. It is usually also known to carers how a pressure ulcer occurs. Unfortunately, attempts are often made using the wrong means in trying to take the pressure off the patient. Old home remedies often toss more harm on the problem than good. The doctor should take more time for the interview with the patient’s family members and communicate skillfully. “Do you know how to prevent a pressure ulcer?” is a wrongly formulated question, because the family member is not aware that he or she commits care errors.
The individual risk of developing a pressure ulcer may by influenced by intrinsic factors which are to be considered in a risk assessment:
- limited mobility or immobility
- sensory limitations
- acute diseases
- impaired state of consciousness
- being of a very young or very old age
- vascular diseases
- severe chronic or terminal illness
- pressure-induced tissue damage in previous medical history
- malnutrition and dehydration
The following extrinsic risk factors contribute to tissue damage and should be minimised or eliminated to prevent injury: pressure, shear and friction forces.
Away with old customs
Most errors in the prevention and treatment of pressure ulcers do not occur by the omission of the correct therapies but by applying the wrong ones. Dry skin needs care, but not all oil products are suitable. Oil baths are useful, but should be made available as emulsion, so that they can mix with water. Putting pure (baby) oil in wash water is useless as it floats on the water surface and does not feed into the skin. Emulsions are only useful if they are of the W/O type (water in oil). With O/W products, the water content is clearly the predominant one. The water penetrates rapidly into the outer skin layer, causes it to swell and increases the surface area. As a result the evaporation of moisture is increased, the skin dries out. Therefore these products should be used only in the care of oily skin. Flour on burn wounds was a formerly propagated mode of treatment and is absolutely outdated. The same value can be attributed to rubbing alcohol as a decubitus preventative. Yet even this “bit of wisdom” stubbornly lives on. This natural product contains large amounts of dehydrating alcohol and is therefore totally unsuitable. However older patients in particular appreciate the refreshing effect and the mountain pine scent and insist on its application. If this should be the case, such an application neeeds to be followed up with treatment using W/O emulsions as appropriate for nursing care.
Milking grease persists just as stubbornly as some kind of secret tip. What sounds rustically natural may be beneficial for the teats of a cow, but not for the care of stressed and decubitus-threatened skin. The product consists percentage-wise as much as 99.5% of the petroleum product Vaseline, the rest being preservative. The grease seals the pores of the skin and makes heat exchange impossible. This nonsense is only increased by the addition of allergenic daisy-family flowers such as chamomile or calendula. What is sensible for use on a baby’s bottom need not be liked by old skin. Zinc paste is a visual cover and makes skin inspection impossible. Zinc oxide dries out the skin and is therefore on the “out” list.
Fire And Ice is out
For years, “icing and heat drying” was practised because this cold-warm interaction promised to improve the blood circulation in the tissue. Studies show that this is a fallacy. The cold of the ice damages the skin, the heat drying dries it out. Among valid causal therapies instead are generally overall stress relief, improved nutrition, pain management and the improvement of general condition. In particular, mobilisation and ample fluid intake are useful.
No case for sheepskins
The following in accordance with the pressure ulcer guidelines should not be used for pressure reduction:
- devices filled with water
- synthetic sheepskins
- genuine sheepskins
- ring pillows
Ring pillows affect lymphatic drainage and therefore are more likely to promote the formation of decubitus than they are to prevent them. Water filled padding beneath the heel are useless since, due to the small surface of the heel, pressure cannot be effectively distributed by these small-scale supports. Sheepskins are perceived by some patients as pleasant, but they are not a pressure-reducing nor a pressure-distributing aid. If sheepskins are employed for the comfort of the patient rather than for the decubitus, care must be taken against the potential infection risk and a proper cleaning of the sheepskins is to be ensured.
These are obsolete forms of decubitus prophylaxis:
- Hyperaemic substances, such as ointments with nicotine or benzoic acid esters
- skin-covering pastes and powders, such as zinc paste, baby powder
- pore-blocking fatty substances, such as Vaseline, baby oil, milking grease
- irritants/ allergenic mixtures such as rubbing alcohol, alcohol
- disinfectant agents
- coloured, mercury-containing mixtures
- Massaging the threatened area of skin
Charcoal-silver wound dressings
Silver-containing activated-carbon pads are ideal for infected chronic wounds. The most important component of this wound dressing is a homogeneously distributed support film made up of an activated carbon layer with elemental silver. The strong antiseptic effect of silver is based on the blocking effect of the silver-containing silver ions within the oxide layer which acts on thiol enzymes and amino acids in the microorganisms. Their metabolism is blocked and death of the germs occurs. The silver coating is firmly fixed to the surface of the activated carbon. The layers are characterised by a high adsorptive capacity for exudates and microorganisms. Germs get attached to the surface and are killed. Good antimicrobial effects have been shown against St. aureus, P. mirabilis, E. coli, E. cloacae, Ps aeruginosa und B. fragilis.
Taking 20 compartments to success
In addition to pharmacotherapy involving dermatological substances, the second pillar of decubitus prevention is the use of positioning aids. In cooperation with three partners, the Department of Nursing Science, University of Witten / Herdecke, has developed an “accompanying” anti-decubitus system. The software detects the position of the patient, sets the system optimally and gives the care nurses indicators on the time points at which additional repositioning procedures need to follow on after that.
The hardware consists of 20 independent air chambers, in which a continuous air stream builds up a certain pressure. This way, pressure relief is achieved. Moreover the system also documents the local pressure load and the remaining mobility of the patient. If the pressure is too high, the system sounds an alarm. The development of the anti-decubitus system was promoted as part of the Central Innovation Programme for Small to Medium Enterprises (ZIM) by the Federal Ministry of Economics and Technology and was awarded as a ZIM project success.
Six pillars of Basel
The six-pillar concept at the hospital in Basel has proven to be a pragmatic anti-decubitus prophylaxis.
1st Pillar: consistent pressure relief (patient positioning on low-air-loss beds)
2nd Pillar: early operative debridement and treatment of an existing infection with antibiotics
3rd Pillar: conditioning of the wound with moist dressings or VAC ®
4th Pillar: quantification and correction of malnutrition
5th Pillar: covering the wound by plastic surgery
6th Pillar: post-operative, consistent relief and mobilisation concept
This treatment concept produced by Rieger et al. has proven itself at the University Hospital Basel over many years. Through this and in combination with a rigorous prevention procedure the decubitus rate was able to be significantly reduced, decubitus ulcers healed and the number of recurrences reduced.
Overview of the types of dressing
Charcoal dressings consist of a fibre composite of previously carbonised cellulose products which absorb odour, act as a bactericide and take up endotoxins. Activated charcoal dressings can be used in particular on bacterially contaminated and heavily exuding wounds.
Alginates are used in the form of calcium or calcium sodium alginates as wound compresses or wound tamponades. They possess the capacity to absorb and through the absorption of wound secretions form a dimensionally stable gel that maintains a moist wound environment. Alginates are employed mainly on wounds with heavy exudation and on heavily moist and deep wounds. If alginates are used as a tamponade, hydrocolloid dressings serve as secondary dressings. Due to their haemostyptic effect alginates are also suitable for the treatment of bleeding wounds.
Hydrocolloids consist of highly swellable material which forms a gel via wound exudation, thus maintaining a moist wound environment and closing the wound hermetically. The gel also binds bacteria and detached particles. The gel remains in the wound with a change of dressing and has to be rinsed off using Ringer solution or NaCl solution. The hydrocolloids support the natural cleansing of wounds, the epithelialisation and the formation of new granulation tissue. Hydrocolloid dressings can be used in all phases of wound healing. The dressing should overlap the wound edge by about 2 – 3 cm, on the one hand to ensure adequate adhesion and on the other hand so as not to macerate the surrounding healthy skin.
Polyurethanes have a high absorption capacity for exudates and necrotic tissue. They are used especially with poorly healing wounds, as the foam can grow into the wound and the wound granulation can be stimulated during dressing changes by the removal of the new skin. However, the open-cell foam compresses previously often used for wound conditioning, into which the granulation tissue grows, is seen today as obsolete because of the painful dressing changes.
Hydropolymer dressings absorb the wound exudate in a structurally stable sponge scaffold, whereby the material swells out, but without becoming liquid. For this reason, it can be removed from the wound without leaving any residue. Application areas include epithelialising and granulating wounds with minor wound discharge.
Hydrofibre dressings stand out for their high absorbency. The fluid taken up by hydrofibres in a matter of minutes is as much as forty times their own weight and is only taken vertically, so as to prevent maceration of the wound edges. A dimensionally stable gel is formed via uptake of secretions, which keeps the wound moist and can be removed without leaving any residue. Hydrofibre dressings are employed on highly secreting wounds.
Silver dressings are widely used today in the form of silver-layered dressings. However, the indiscriminate application of silver-coated wound dressings is not advisable because of resistance development and the emergence of gaps in the bacterial spectrum is unavoidable with prolonged use. Short-term use of silver coated dressings is recommended for critically infected wounds.