A study from the Cleveland Clinic Journal of Medicine indicates that when it comes to treating pressure sore wounds, an “occlusive dressing” might be a patient’s best option. Occlusive dressings are air- and water-tight covers that retain some of the wound’s original moisture. Unlike traditional gauze dressings, which tend to cause pain when removed, occlusive dressings rarely cause secondary trauma.

“In both acute and chronic wounds, the principal function of a wound dressing is to provide a moist healing environment,” the study says. “Removal of [wound dressings] by aggressive scrubbing or drying has been shown to be detrimental.”

The study recommends that doctors not change occlusive dressings until they leak, a period typically lasting several days to three weeks. The study also indicates that saline-soaked gauze may be an acceptable alternative to occlusive dressings, as long as the gauze is not allowed to dry.

According to the National Pressure Ulcer Advisory Panel (NPUAP), the leading authority on pressure ulcer research and information, a “deep tissue injury’ (DTI) as ‘a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.”

The NPUAP goes on to describe the progression of the injury as,

the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.  DTI many be difficult to detect in individuals with dark skin tones.  Evolution may include a thin blister over a dark wound bed.  The wound may further evolve and become covered by thin eschar.  Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

A DTI can occur in a hospital, nursing home or any setting where a patient is left on a hard surface for an extended period.  However, some of the group most prone to develop DTI’s are patients receiving acute-care in a hospital or those undergoing lengthy surgery.  For this reason it is not uncommon for medical facilities to claim the DTI’s are unavoidable and simply part of the medical process.

In some cases the extent of the DTI may not be known until the patient has been discharged from the facility to a rehabilitation center or home due to the fact that the overlying skin may remain intact for 10-14 days following the initial deep tissue injury.

If you believe a family member has suffered a deep tissue injury during an admission to a hospital or nursing home, be sure to obtain medical attention as soon as the injury become apparent.  In many cases, it can be helpful to take photos of the area after there is an indication of a deep tissue injury to preserve your future legal rights.

Related:

Are All Pressure Ulcers the Result of Deep Tissue Injury? A Review of the Literature, Ostomy and Wound Management, VOLUME: 53 Issue Number: 10 authored by, Dan R. Berlowitz, MD, MPH; and David M. Brienza, PhD

Hypoxia is Involved in Deep Tissue Injury Formation in a Rat Model, Wounds, February 1, 2010 by Yunita Sari, MHS; Takashi Nagase, MD, PhD; Takeo Minematsu, PhD; Tomoko Akase, RN, RPh, PhD; Gojiro Nakagami, RN, PhD; Hiromi Sanada, RN, WOCN, PhD; Junko Sugama, RN, PhD

Pressure Ulcers: What Clinicians Need to Know, The Permanente Journal Summer 2010 – Volume 14 Number 2 by William T Wake, MD, FAAFP

The NPUAP further defines unstageable bed sores as “enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.”  Obviously, an unstageable bed sore is considered to be severe and requires immediate medical attention.

Like most bed sores, Kennedy ulcers are believed to develop due to poor blood circulation that results from unrelieved pressure. However, Kennedy ulcers, differ from other bed sores because of:

• Rapid onset, a wound may go from a blister to stage 4 within hours
• The wounds tend to grow downward, as opposed to horizontally
• The wounds are most often located on the sacrum
• Wounds are almost exclusive to the elderly population
• The wounds are usually irregularly shaped, frequently described as pear shaped
• Death occurs quickly, many patients succumb to kennedy ulcers within 24-48 hours of their onset

The treatment options for people with Kennedy ulcers are limited due rapid development and progression. Consequently, most treatment for Kennedy uclers is focused on providing pain relief.

Resource:

Kennedy Terminal Ulcer LLC

The primary reason for not ‘reverse staging’ bed sores is that despite an outward appearence that a wound may be healing, bed sores simply do not completely heal. An advanced bed sore that appears to be healed, will still be unable to replace lost muscle, fat and skin that were lost due to the original wound. Therefore, reverse staging does not accurately characterize what is physiologically occurring in the bed sore.

Once a bed sore is categorized as a particular stage, it should always remain that stage– regardless of the outward appearance.

Source:

National Pressure Ulcer Advisory Panel

Stage 1- Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

Stage 2- At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin’s deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

Stage 3- By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.

Stage 4- In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections. If you use a wheelchair, you’re most likely to develop a pressure sore on: Your tailbone or buttocks Your shoulder blades and spine The backs of your arms and legs where they rest against the chair When you’re bed-bound, pressure sores can occur in any of these areas: The back or sides of your head The rims of your ears Your shoulders or shoulder blades Your hip bones, lower back or tailbone The backs or sides of your knees, heels, ankles and toes.

Occasionally, a bed sore may be categorized as ‘unstageable‘.  Unstageable bed  sores are usually referred to as an extremely advanced wound where there is involvement of skin, muscle and bone.

Because of their tendency to develop deeply into the bodies layers of skin, fat, muscle and bone, tunneling bed sores can be particularly difficult to treat.  Many patients with tunneling bed sores require extensive medical treatment such as surgical debridement.  If left untreated, tunneling bed sores may be fatal.

Bed sores can form from one intense period of hard pressure, but usually occur when blood flow to skin, muscle, fat and tendons is restricted over longer periods of time.  Because the entire body relies upon a well oxygenated supply of blood, a reduction in blood supply causes the body to shut down, and those areas of the body die and wounds develop.

• Being bedridden or in a wheelchair
• Fragile skin
• Having a chronic condition, such as diabetes or vascular disease, that prevents areas of the body from receiving proper blood flow
• Inability to move certain parts of your body without assistance, such as after spinal or brain injury or if you have a neuromuscular disease (like multiple sclerosis)
• Malnourishment / dehydration
• Bladder or bowel incontinence
• Mental disability from conditions such as Alzheimer’s disease
• Older age