June 2009 Archives

Patients residing at nursing homes are often at risk of developing pressure sores/decubitus ulcers as a result of their underlying health problems and immobility issues.  A pressure sore/decubitis ulcer is a bedsore that comes from lying in the same position too long and is associated with pain.  "Decubitus" is the Latin-phrase for "lying down."

Most physicians would agree that the minimal standards of care applicable to such nursing homes is: (1) to ensure that a resident entering the facility without pressure ulcers ulcers does not develop them unless the resident's clinical condition demonstrates that they were medically unavoidable; and (2) ensure that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing.  This includes turning and repositioning the resident at least every two hours while in bed and every hour while in a chair, the maintenance of adequate nutrition and hydration, and the prevention of contractures of the extremities.

Nursing home patients experience pressure from the bed and/or chair to certain points on their skin preventing the blood from flowing into those points.  Because the blood is not allowed to flow into those points, the skin, deprived of nutrients and oxygen, can become injured and susceptible to infection.

Pressure is a primary contributing factor to the development of pressure ulcers.  Since the development of pressure ulcers depends on the length of time pressure is applied, immobility is the major risk factor.  Pressure must be relieved.  Malnutrition and adequate hydration have been linked to the development of pressure ulcers.

A stage one ulcer presents as redness of the skin and represents tissue injury and heralds skin ulceration.  A stage one ulcer is classified as nonblanchable erythema with intact skin.  Erythema is redness of the skin produced by congestion of the capillaries.  Erythema is the initial reactive hyperemia caused by pressure, and nonblanchable erythemia represents s stage one pressure ulcer.

A stage two ulcer is characterized by partial-thickness skin loss, that is, the epidermis is interrupted as an abrasion, blister or shallow crater.

A stage three ulcer features full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, the underlying fascia.  The ulcer appears as a crater, with or without undermining of adjacent tissue.

A stage four ulcer involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., a tendon or a joint capsule).

With stage 3 or 4 pressure ulcers, the extent of the disease may not be evident because of covering necrotic material or eschar.  To establish the extent of the disease and promote healing, the necrotic material needs to be removed and surgical consultation may be required.  When ulcers develop over bony prominences, osteomyelitis is a potential complication.  Pressure ulcers are chronically contaminated wounds and the combination of bacteremia and pressure sores can be painful and life threatening.

Ultimately, pressure ulcers are avoidable so long as proper care and preventative measures are instituted and implemented by the nursing home.  In fact, under new Medicare guidelines, hospitals are no longer reimbursed for additional care resulting from bed sores and several other "reasonably preventable" errors including objects left in the body after surgery. The government has determined that development of bedsores at a hospital is a so-called "never event."
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