Coursework bedsores. Prevention and treatment of bedsores

MINISTRY OF HEALTH OF THE CHECHEN REPUBLIC

STATE BUDGET EDUCATIONAL INSTITUTION
SECONDARY VOCATIONAL EDUCATION

"CHECHEN BASIC MEDICAL COLLEGE"

COURSE WORK
(discipline)
for the specialty 060102 Obstetrics

On the topic "_____________________________ _____________________________"

Completed by (a) ____FULL NAME _______________________
student (ka) ___________ course _________ group

Checked by _____ Name _______________________
Teacher ______________________________ _
Academic degree, title, category

Evaluation ________________ /signature/
The date __________________________

G. Gudermes 2013
Table of contents

INTRODUCTION ……………………………………………..…… …………………...3
CHAPTER I. DEDUCING SORES…………. ………………...………………………….four
1.1 What are bedsores? .............................................. ...... .............................. .....four
1.2 Clinical picture of bedsores ……………………………………...5
1.3 Causes of bedsores ………………………………………………...…..8
1.4 Risk factors …………………………………………………………….11
1.5 Complication ……………………………………………………….…….13
1.6 Examinations and diagnostics ……………………………………....….14
1.7 Prevention of bedsores …………………………………………..…15
1.8 Treatment of bedsores ……………………………………………………….18
CHAPTER II. PRACTICAL PART ………………………………………25
Conclusion …………………………………………………………….…………27
List of used literature ……………………………………….…..28

INTRODUCTION

The skin is one of the most important organs that ensure the integrity of the human body, the constancy of the internal environment of the body, protection from chemical, physical and biological factors.
The skin consists of the epidermis, the surface layers of dead cells of which form a horny protective layer, and the skin itself (dermis), which contains blood vessels, sebaceous and sweat glands, and nerve endings. It is important to note that oxygen (up to 0.1% of the total gas exchange of the body) enters through the skin, which goes mainly to supply the cells of the epidermis.
For the normal functioning of the skin, certain conditions must be met: it must be clean (pollution impairs gas exchange); elastic, which is achieved by lubricating the skin with fat from the sebaceous glands; get enough nutrition through the blood vessels. The metabolism in the skin is very intense, which requires constant intense blood flow.
In many diseases, conditions arise that lead to damage to the skin like pressure sores.

CHAPTER I

1.1 What are Pressure Sores?

Decubitus (decubitus - lat.) - These are areas of damage to the skin of a dystrophic or ulcerative-necrotic nature, formed as a result of prolonged compression, shift or displacement between the human skeleton and the surface of the bed.
Most often, bedsores are formed in the buttocks, sacrum, ischial tubercles, heels, and legs when the patient is in the supine position.

The first sign of the development of bedsores is the pallor of the skin areas, followed by their redness, swelling and flaking of the epidermis. Then blisters and skin necrosis appear. In severe cases, not only soft tissues are subjected to necrosis, but also the periosteum and the surface layers of the bone substance. Accession of infection can lead to sepsis and be the cause of death of the patient.
In the development of necrobiotic processes in pressure sores, three stages are distinguished:
Stage 1 (circulatory disorders) - characterized by blanching of the corresponding area of the skin, which is quickly replaced by venous hyperemia, then cyanosis without clear boundaries; tissues become edematous, cold to the touch. At this stage, with the exogenous development of bedsores, the process is still reversible: the elimination of tissue compression usually leads to the normalization of local blood circulation. With a bedsore of endogenous origin (and with continued pressure on the tissues with an exogenous pressure sore), at the end of stage 1, vesicles appear on the skin, which merge, cause detachment of the epidermis with the formation of excoriations.
Stage 2 (necrotic changes and suppuration) - characterized by the development of the necrotic process. In addition to the skin, subcutaneous tissue, fascia, tendons, etc. can undergo necrosis. With an exogenous bedsore, the formation of dry necrosis is more often observed, the rejection of which proceeds with the participation of a saprophytic infection; with an endogenous bedsore, an inflammatory process usually develops caused by pathogenic microflora, and wet gangrene develops with symptoms of intense suppuration.
Stage 3 (healing) - characterized by the predominance of reparative processes, the development of granulation scarring and partial or complete epithelialization of the defect. The clinical picture may be different depending on the etiology of the bedsore, the patient's condition, the presence of pathogenic microflora, the nature of necrosis, etc.
At stage 1, patients rarely complain of severe pain, more often they note weak local pain, a feeling of numbness. In patients with spinal cord injury, erythema may occur within a few hours, and after 20-24 hours, small areas of necrosis already appear in the sacral region. With endogenous mixed bedsores, the transition of the pathological process to stage 2 occurs much more slowly.
In cases where the bedsore develops as dry necrosis, the general condition of the patient is not noticeably aggravated, intoxication phenomena do not occur. Mummification is subjected to a strictly limited area of the skin and underlying tissues, there is no tendency to expand necrosis in area and depth. After a few weeks, the mummified tissues begin to gradually shed, the wound heals. Such a clinical course of pressure sores is the most favorable for the patient.
With the development of a decubitus according to the type of wet necrosis, dead tissues acquire an edematous appearance, a fetid turbid liquid separates from under them. In decaying tissues, pyogenic or putrefactive microflora begins to multiply rapidly and wet gangrene develops, called decubital gangrene.
The process of decay and suppuration spreads over the area and deep into the tissues, quickly reaching the bones, which are often exposed in the area of bedsores. Decubital gangrene leads to a serious deterioration in the general condition of the patient. Clinically, this is manifested by signs of purulent-resorptive fever - a rise in temperature to 39-400C, increased respiration, tachycardia, muffled heart tones, a decrease in blood pressure, an increase in the liver. In the blood, leukocytosis with neutrophilia, accelerated ESR, dysproteinemia are detected; anemia, proteinuria, hematuria, pyuria, etc.
Pressure sores can be complicated by phlegmon, abscess, purulent swells, erysipelas, purulent tendovaginitis, arthritis, gas phlegmon, anaerobic infection, cortical osteomyelitis, etc. The most typical complication for severely weakened patients is the development of sepsis. When caring for a patient who has a tendency to develop pressure sores, every effort should be made to avoid them. By taking the necessary measures, the danger can be significantly reduced.

The main reasons for the formation of bedsores are blockage of blood circulation and lack of movement of the patient. The blood flow is mainly blocked by the weight of the body in the area of the bony protrusions, which compress and press the soft tissues against the surface of the bed or chair, thereby blocking the blood vessels.
Sometimes soft tissues are compressed when the patient's body rests against sanitary or medical equipment. Badly placed dressings, splints, catheters, bedpans can contribute to the formation of bedsores. Almost any hard object that presses against the skin can be dangerous if the patient cannot move normally. Items such as buttons, knots in clothing, pins, and other small objects in bed can, under the patient's body, create areas of high pressure where blood flow is blocked.
Pressure as well as shear forces are the most important reasons why circulation is blocked and pressure sores form as a result. Damaged skin and soft tissues are more than healthy, prone to the risk of bedsores in violation of normal blood circulation. Many causes can lead to skin damage.
When the outer layers of the skin are scratched or frayed, an abrasion occurs. Usually this phenomenon is accompanied by itching and scratching. Patients whose skin itches for any reason can also comb it. Sometimes the abrasion is so small that it is barely visible, but it can be dangerous because the surface of the skin is already damaged. You have all seen what happens to children's knees when they fall. The same thing happens to the patient in bed when he rests his elbows and heels on the surface of the bed, trying to move. He slides, rubbing his elbows and heels against the sheet in such a way that it turns out, as it were, a “burn” from friction. This also happens when an immobile patient is pulled across the bed, with the skin rubbing against the sheet. If the sheet is made of coarse linen and starched, then the likelihood of getting a "burn" from friction is even greater.
The same motions that cause a friction "burn" can create shear forces that can damage the soft tissue under the skin if the tension is so strong that it tears the tissue.
Ordinary adhesive tape can be dangerous for patients' skin. When applied unevenly, the patch will stretch or compress the skin, forming folds. When the patch is removed from the surface of the skin, the top layer of the skin is torn off, making it thin and easily damaged. The skin of some patients is hypersensitive to the patch and thus may experience an allergic reaction.
Skin that is too dry can peel, peel, or crack, breaking the integrity of the inner layers. Bacteria can enter through the cracks and multiply on the surface of the skin and inside tissues.
Skin that is too wet also has less resistance to damage. Skin that is wet for too long becomes swollen, soft, and easily injured by scratching or rubbing. Patients who cannot control bladder or bowel activity need additional nursing care. It is important to prevent prolonged wetting of the skin, ensuring the change of clean bed linen. Excessive sweating in hot weather or at elevated body temperature is also a problem that needs to be addressed. Discharge from open wounds, sometimes from pressure sores themselves, can soften and inflame the surrounding skin.
Infection of the skin and soft tissues leads to their damage and affects deeper tissues. Dirty, too dry or too wet skin is especially prone to infection.
Medicines applied to the skin can often cause damage to the skin. Some of them, being strong chemicals, directly harm the skin; others cause an allergic reaction. Even soap used to wash the body can cause skin irritation and inflammation if it is too rough or not completely rinsed off.
Poor nutrition is detrimental to the health of any person. If the patient does not receive enough water, protein and other essential elements, including certain vitamins and minerals, then his tissues will not be able to resist the occurrence of damage and recover from them.

Any person with limited mobility is at risk for pressure sores. Immobility can occur due to:

Other factors that increase the risk of pressure ulcers include:

Pressure ulcer complications include:

Decubitus Severity Assessment
For this you need:

What questions should you ask the patient or caregiver?

Laboratory research

Pressure ulcer prevention is based on:
early risk assessment,
reduction of tissue compression time,
reduction in surface pressure and
complex treatment.
Early risk assessment
A pressure ulcer can develop within three to four hours if the appropriate risk factors arise suddenly (in most cases at night). The decisive moment for the start of preventive measures should not be missed, and the prophylaxis itself should in no case begin only after redness has already appeared in places typical for bedsores. Therefore, special medical personnel should regularly, several times a day, examine patients for risk factors. The most common risk factors that occur suddenly at night are high fever, cerebrovascular stroke with paralysis, clouding of consciousness up to coma of any origin (cerebral, medical, due to insufficiency of the circulatory system, metabolic), falling to the floor when being on a hard floor is detected not right away. For early recognition of additional risk factors, one should take into account the list of factors presented, or apply the Norton-type rating scale.
Reducing tissue compression time
The goal of prevention is to improve mobility so that pathological, disease-related low sacral mobility can be normalized by medical interventions (for example, treatment of immobilizing diseases) and/or by reducing the time of compression by shifting the patient from one position to another as often as necessary. The positions that can be given to the patient depend on the location of the bedsore. In this case, the position on the right or left side at an angle of 30 ° refers to the position with a minimum degree of risk, which can be used in any localization of the ulcer. To achieve a physiological index of sacral mobility in absolutely immobile patients, they need to provide them with 4 position changes per hour at night. Therefore, such patients need to be shifted every 15 minutes, which, although highly effective (over 98% reliability), is perhaps hardly feasible. However, the short-term use of this option as a temporary measure should be tested where there is a high risk of pressure ulcers over a period of time, such as in severely malnourished, cachectic patients with high fever pneumonia and multiple associated pathological symptoms. This raises the question of the need for fast and flexible measures. After adequate treatment, you can switch back to standard prophylaxis. As an effective standard prophylaxis, a real alternative is the transfer of the patient every 2 hours, which guarantees a high efficiency - more than 90%. This preventive method is applicable everywhere (!) and immediately, including on a normal hospital mattress and without special auxiliary devices. If a special soft mattress is used, one shift every 4-6 hours is enough for standard prophylaxis. The frequency of shifting depends on the condition of the skin during daily morning care. If the area of the skin is reddened, the patient should be shifted so often until the hyperemia ceases to appear. With a shortage of attendants, when patients stay at home, in patients with painful bone metastases, and to maintain nightly rest for patients, modern anti-decubitus mattresses are used today. Such mattresses (for example, the type of automatic mattresses from Turnsoft) transfer patients from one position to another automatically, but at the same time gently and slowly. During the automatic movement of the anti-decubitus mattress, the patient feels practically nothing, he does not experience pain and sleep is not interrupted.
Surface pressure reduction
In this case, the goal of prevention is to reduce the force of surface pressure in all five classic zones of localization of bedsores to values less than 25 mm. rt. Art. using soft anti-decubitus mattresses. A distinction is made between typical static anti-decubitus mattresses for standard prophylaxis and special high-performance dynamic mattresses. By measuring transcutaneous oxygen tension (tcPO2) it is possible to prove the effectiveness of this system. If a healthy proband lies on his back on a hard hospital mattress, tcPO2 in the skin of the sacral region drops to 0 kPa. If instead a special soft mattress is used that lowers the surface pressure to less than 25 mm. rt. Art., tcPO2 in the skin of the sacral region remains within the normal range in 95% of young healthy probands and more than 85% of elderly patients. If, with frequent shifting, every two hours, reddening of areas of the skin continues to appear, for example, in patients with a very high risk of pressure ulcers, in cachectic patients with bone metastases or multiple accompanying pathological symptoms and numerous risk factors, a static system is not enough. Here, a transition to a dynamic anti-decubitus system is necessary. Such a system, operating, for example, according to the principle of "air resistance reduction", reduces the surface pressure to a level below 25 mm. rt. Art. and therefore very efficient.

In addition to the early detection of the risk of pressure ulcers and the timely initiation of preventive measures, accurate diagnosis of diseases with a multimorbid background and their treatment are crucial for effective prevention of pressure ulcers. This applies especially to the treatment of depression, loneliness, infections and malnutrition, as well as to the improvement of the general condition of patients. Additional measures to eliminate risk factors are characterized by a decrease in the risk of pressure sores.
Systemic treatment of bedsores according to the Basler concept
Decubitus ulcers demonstrate a typical clinical picture of impaired wound regeneration (poor wound healing), in which, in the area of damaged tissues, in most cases there is a significant pathological change in metabolism. Therefore, the primary goal of every ulcer treatment is to restore physiological conditions in the wound, since regeneration within the framework of wound healing can proceed in a chronologically correct sequence only when normal physiological processes take place in the wound surface (as large as possible). According to Zederfeld (1980), wound healing is not accelerated beyond the norm. If wounds or ulcers heal poorly or do not heal at all, this may be due to the presence of factors that slow down the healing of the wound, and not to a lack of wound healing medications. Hence, it is advisable to conduct a regular search for local and general pathological factors. The healing of pressure sores is often delayed for many months and in the elderly is a particular problem, which often remains unresolved. Last but not least, this may be due to the fact that it is difficult to carry out complex treatment of pressure ulcers and chronic wounds with simple and standard therapeutic planning. On the contrary, medicine and general nursing require an individual approach for each patient, in which the characteristics of the course of the disease and living conditions are taken into account in as much detail as possible. In doing so, it may be useful to focus on exemplary therapeutic principles, which are used as a checklist. An example of therapeutic principles presented by the Geriatrics University Hospital of the Cantonal Hospital in Basel promotes consistent and organized action in the treatment of pressure ulcers:
complete elimination of pressure
removal of dead tissue
treatment of local infections (and, if necessary, osteomyelitis and sepsis),
continuous hydration therapy with Ringer's solution for wound treatment, diagnosis and long-term monitoring of local and general pathological factors that impede wound healing, as well as accurate diagnosis of malnutrition and subsequent targeted therapeutic nutritional correction,
studying the possibilities of plastic surgery and, as necessary, performing plastic surgeries.
Ensure complete elimination of pressure
In accordance with the cause that caused the formation of a bedsore, the most important measure in each treatment is the complete elimination of compression in order to improve, or rather, restore blood circulation in the tissues of the affected skin area. Without this, healing is impossible, and all further activities will be meaningless. Sufficient pressure reduction can be achieved by shifting the patient every 2 hours to the left and right side at an angle of 30°, as well as through the combined use of static and dynamic aids to unload the compressed area. For large pressure ulcers, for patients with multiple risk factors and undergoing surgery associated with pressure ulcer surgery, anti-decubitus mattresses are used, working on the principle of "reducing air resistance", in order to achieve highly effective unloading of the squeezed area.
Thoroughly remove dead tissue
Necrotic areas are always removed. The exception is necrotic masses in the heel area. Here, they are removed only when the aforementioned arterial embolic peripheral vascular disease has been ruled out or a recanalization operation has been successfully performed. Necrotic tissues should be excised as early as possible, since infection can spread unnoticed in the thickness of the wound under them. The risk of decubitus sepsis or osteomyelitis in this case increases rapidly. In addition, necrotic masses contribute to the chronicity of the process. Because of the morbidity and possible complications, surgical debridement should, if possible, be performed by a medical specialist with experience in plastic surgery.
Don't miss local infection and sepsis
Local infection and periulcerative bacterial dermatitis are very common complications. If they are not detected in a timely manner, percutaneous decubitus sepsis may develop or osteomyelitis may imperceptibly form. Local infection necessarily begins with classic symptoms: hyperemia and local temperature increase on the skin, a ring surrounding the ulcer, burning pains at the base of the ulcer and around the wound, pain on pressure and swelling at the edge of the wound and around it. With systemic pathology, fever, leukocytosis, and an increase in C-reactive protein values are expected, and these symptoms are often absent in elderly patients. Diagnosis is significantly helped by a biopsy of a small piece of tissue for examination for bacteriological culture. It makes it possible to prescribe targeted antibiotic therapy for likely incipient decubitus sepsis. If the infection is localized, antibiotics are not needed. In the same way, the need for topical disinfectants is denied today. Studies show (Cooper et al. 1991, Forzeman et al. 1993, Lineweaver et al. 1985) that disinfectants are more harmful to keratinocytes, fibroblasts and granulation tissue than to bacteria. In addition, disinfectants destroy essential elements of granulation tissue such as cytokines, growth factors, locally produced protective factors such as immunoglobulins (IgA), as well as macrophages, leukocytes and lymphocytes. On the contrary, continuous moistening of the wound surface with harmless solutions, such as Ringer's solution, preserves all these elements, which are extremely important for wound healing. In addition, disinfectants do not reach those bacteria that cause an infectious process in the thickness of the skin tissues.
Keep the wound moist
Wounds heal better with wet dressings than with dry ones (Winter, 1962). Continuous hydration therapy has a very good wound cleansing effect, preserves the cells of the immune system, contributes to the formation of a wound healing microclimate and promotes the formation of granulation tissue. The drying of the wound is reduced, which preserves epithelial cells and their ability to migrate along the wound surface. It should also be noted and analgesic effect. The task of dressing the wound is as follows: protecting the ulcer from external mechanical damage, from drying out and hypothermia, as well as from external bacterial contamination. Covered dressings (material made of aluminum or plastic) as well as topical application of powder, ointments, disinfectants or antibiotics interfere with the healing process. Since the treatment of ulcers is long, i.e. is a long-term therapy, only non-toxic components such as Ringer's solution should be used. Ringer's solution is physiological and non-toxic. In this solution, fibroblasts survive under experimental laboratory conditions for several days, since Ringer's solution, in addition to 8.60 g of sodium chloride, also contains 0.30 g of potassium chloride, 0.33 g of calcium chloride per liter. This corresponds approximately to the concentrations in millimoles per liter: sodium ions 147, potassium 4.0, calcium 2.2 chlorine 156 and a theoretical osmolarity of about 309 mOsm/l. In the so-called physiological saline solution, fibroblasts, on the contrary, die after a short time (Kallenberg et al., 1970). Since Ringer's solution reproduces conditions similar to these cell cultures, wound dressings should be continuously moistened with this solution. In any case, drying of the bandage should be avoided, since a bandage that has dried, for example, overnight, when changing bandages, tears off newly formed epithelial cells, causing severe pain and removing many of the most important components for wound healing from the wound. In order to facilitate moisture retention in practice, hydration therapy can be carried out with a special dressing, which is a multi-layer cushion-shaped wound dressing, which contains the superabsorbent polyacrylate as the main ingredient of its base, which performs an absorbent and rinsing function. The release of the active substance of the superabsorbent before use is activated by an appropriate amount of Ringer's solution (however, there is also a form with a ready-to-use base impregnated with Ringer's solution), which then enters the wound over several hours. Through this continuous delivery of Ringer's solution, the necrotic masses are softened, separated and washed out. Superficial grade II ulcers with a depth spread of less than 2 mm restore blood circulation. They fill neatly with granulation tissue, which is a sign of optimal oxygen supply. Here, as a bandage, it is enough to use a thin gauze soaked in fat or paraffin.
Systematically look for pathological factors
If ulcers do not granulate or even heal, additional pathological factors preventing healing should be sought (Table 1). This must be done daily. In addition to insufficient unloading of compressed skin areas, malnutrition is the most common cause of poor wound healing tendencies. All patients with grade II pressure ulcers and above show signs of malnutrition (Gengenbacher et al., 2002). Therefore, the list of studies upon admission of the patient includes monitoring the state of nutrition.
The simplest way to identify malnutrition is by using nutrient saturation scores. Malnutrition in elderly patients is mainly indicated by the following parameters: low serum levels of albumin, zinc, selenium, iron, vitamin B 12, folic acid, and absolute white blood cell count. If pathological indicators are found in the state of nutrition, a targeted therapeutic correction of the diet is carried out with the replacement of the corresponding elements.
Explore the possibilities of plastic surgery
Thanks to the progress of surgical technologies, new standards of plastic surgical interventions are being set, which make it possible to benefit, first of all, for age-related patients with grade III-IV pressure ulcers. Ulcers with such a severe course do not heal without plastic surgery or only heal after a few months or years, which not only does not suit the patient and the therapist, but also represents a serious economic burden on the entire health care system. According to Basler's concept, ulcers are subject to surgical intervention, if the general condition of patients allows. Plastic closure of the ulcer is performed only when nutritional indicators show an upward trend, albumin has reached a value of at least 30 g/l, and the absolute number of lymphocytes is at least 1500 mm3 (Lüscher, 1989, Rieger et al., 2007).

CHAPTER II. PRACTICAL PART

Patient Kazbekov Amir Ruslanovich, 1967, 45 years old, was in the 5th spinal department of the City Clinical Hospital No. 67 from 03.03 to 04.22.2012. He was admitted with complaints of high fever, malaise, weakness, fecal and urinary incontinence and the presence of bedsores in the sacrum. From the anamnesis it is known that in 1997 as a result of a car accident he received a severe spinal injury with damage to the spinal cord at the level of 6-7 vertebrae. Immediately after the injury, lower paraplegia developed with dysfunction of the pelvic organs, bedsores of both trochanters formed, which healed after conservative treatment. Subsequently, the patient developed para-articular ossifications in the area of the hip joints, which squeezed the femoral artery on the right and eventually led to gangrene of the right lower limb. On this occasion, in 2002, she was amputated at the level of the upper third of the thigh.
A deep decubitus of the sacrum developed 5 weeks prior to admission. After unsuccessful conservative outpatient treatment and worsening of the general condition, the patient was hospitalized. Upon admission to the hospital bedsores of the sacrum with an area of about 200 cm 2 with scar-changed undermined edges and inflamed surrounding soft tissues. The bedsore reached the sacrum, there was a purulent-necrotic lesion of the subcutaneous tissue, fascia and underlying muscles.
In the hospital, detoxification and intensive infusion-transfusion therapy with protein preparations was carried out. At the same time, preparations were made for surgical treatment of the bedsore by partial necrectomy (bandages with antiseptic preparations). The improvement of the general condition and the cleansing of the bedsore from necrotic tissues occurred within 2 weeks. The decubitus was removed as a "single block" together with scar-changed surrounding tissues. Then, to the left of the wound in the left gluteal region, a musculoskeletal flap was cut, which was rotated to the tissue defect in the sacral region. The donor wound was sutured edge to edge without much tension. The drainage was removed on the 5th day, the sutures were removed on the 15th day after the operation. When observed for 1.5 years, no recurrence was noted.

Conclusion

One of the most serious complications of immobilization is the occurrence of pressure sores. Its appearance in patients in most cases is tantamount to a serious illness, not to mention the significant investment of time and material resources necessary for the appropriate treatment of pressure sores. Despite the presence of a large selection of various means that facilitate patient care, the number of patients with bedsores does not decrease, which significantly slows down the treatment process, and sometimes leads to the death of the patient. Adequate prevention of bedsores can prevent their development in patients at risk in more than 80% of cases. Thus, adequate prevention of bedsores will not only reduce the financial costs of treating pressure ulcers, but also improve the patient's quality of life.

List of used literature

Work description

The purpose of the study: the study of pressure ulcers, their types, stages and causes of occurrence, as well as nursing activities in the prevention of pressure ulcers.
Object of study: bedsores, their prevention and timely treatment.
Subject of study: the activities of medical personnel in the prevention of bedsores.
Research objectives:
study of the concept of bedsores, consider their types, stages and causes of occurrence;
consideration of the actions of the nurse in the prevention of pressure ulcers;

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Chapter 1. Theoretical aspects of the formation of bedsores, their stages and types …………………………………………………………………………….

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Chapter 2. Prevention and treatment of bedsores ………………………………
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2.1 Nurse's actions to prevent pressure ulcers …………………….
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2.2 Algorithm of manipulations by a nurse for the prevention of bedsores ………………………………………………………………………

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List of used literature …………

Files: 1 file

State Autonomous Educational Institution of Secondary

professional education "Baikal Basic Medical College of the Ministry of Health of the Republic of Buryatia"

COURSE WORK

"Decubituses"

Done: student

Efimova Elena

2 group courses

nursing

Nurse

Supervisor:

Ermakova N.I.

Discipline:

_________________

Selenginsk, 2014


Introduction …………………………………………………………………………
Chapter 1. Theoretical aspects of the formation of bedsores, their stages and types …………………………………………………………………………….
1.1 Pressure sores, their causes ………………………………….
1.2 Types and stages of bedsores ………………………………………………….
Chapter 2. Prevention and treatment of bedsores ………………………………
2.1 Nurse's actions to prevent pressure ulcers …………………….
2.2 Algorithm of manipulations by a nurse for the prevention of bedsores ………………………………………………………………………

2.3 Treatment of bedsores …………………………………………………………
Conclusion ……………………………………………………………………
List of used literature ………………………………………..
Applications

Introduction

The relevance of research. Patients deprived of proper care recovered slowly, often with inadequate care causing serious complications and even death of the patient. The main task of medical personnel in the care of seriously ill patients is the prevention of bedsores.

The main reason for the development of bedsores is increased external pressure on soft tissues for long periods of time, which leads to compression of small blood vessels that provide blood microcirculation in the skin and underlying tissues. As a result, the blood supply to these tissues deteriorates, and trophic disorders develop. Over time, ischemia increases and necrosis occurs. The intensity of the process of formation of bedsores depends on the magnitude of external pressure and the time of its exposure. The greatest risk of pressure sores occurs in the place where the pressure created by body weight and the resistance from the supporting surface act on the area of the skin that lies above the bony prominences and has a slight layer of subcutaneous adipose tissue. These are the sacral region, heels, ischial bones, large skewers, etc.

The skin consists of the epidermis, the surface layers of dead cells of which form a horny protective layer, and the skin itself (dermis), which contains blood vessels, sebaceous and sweat glands, and nerve endings. It is important to note that oxygen (up to 0.1% of the total gas exchange of the body) enters through the skin, which goes mainly to supply the cells of the epidermis.

For the normal functioning of the skin, certain conditions must be met: it must be clean (pollution impairs gas exchange); elastic, which is achieved by lubricating the skin with fat from the sebaceous glands; get enough nutrition through the blood vessels. The metabolism in the skin is very intense, which requires constant intense blood flow.

In many diseases, conditions arise that lead to damage to the skin like pressure sores.

The purpose of the study: the study of pressure ulcers, their types, stages and causes of occurrence, as well as nursing activities in the prevention of pressure ulcers.

Object of study: bedsores, their prevention and timely treatment.

Subject of study: the activities of medical personnel in the prevention of bedsores.

Research objectives:

study of the concept of bedsores, consider their types, stages and causes of occurrence;

consideration of the actions of the nurse in the prevention of pressure ulcers;

the study of devices necessary for the prevention of bedsores;

Pressure sores appear in almost all patients with severe spinal cord injury. The risk of developing this complication in patients with spinal cord injury is higher than in other groups of patients. This is due to the fact that the neurodystrophic process is combined in this group of patients with neurological disorders: violation or lack of sensitivity and movements, and loss of control over the function of the pelvic organs.

Patients with spinal cord injuries with soft tissue bedsores are feared and “disliked” by doctors of almost all specialties. These patients, in the presence of even small bedsores, are not taken to sanatoriums and rehabilitation centers, since rehabilitation measures are contraindicated for them, because of the danger of generalization of the purulent process. Therefore, they are forced to be treated in purulent departments of urban, rural hospitals at their place of residence or at home. Many of these patients die from septic complications.

Practical significance.

Algorithms for the treatment of bedsores in patients with pressure sores have been created, allowing doctors and nurses in contact with these patients to choose the right treatment tactics.

Structure and scope of work. The work consists of an introduction, two chapters, a conclusion and a list of references, applications.

1. Theoretical aspects of the formation of bedsores, their stages and types

1.1 Pressure sores, their causes

Decubitus (decubitus - lat.) - These are areas of damage to the skin of a dystrophic or ulcerative-necrotic nature, formed as a result of prolonged compression, shift or displacement between the human skeleton and the surface of the bed. Most often, bedsores are formed in the buttocks, sacrum, ischial tubercles, heels, and legs when the patient is in the supine position.

Pressure ulcers are tissue injuries that occur most often in areas of the body where the skin adheres to bony prominences. Pressure sores can be superficial, caused by local irritation of the skin, and deep, when changes occur in the underlying tissues. Deep bedsores often go unnoticed until the top layers of the skin are affected.

The cause of most pressure sores is pressure, especially in areas of the body where the skin adheres to bony prominences. This disrupts blood circulation. The severity of the injury depends on the intensity and duration of exposure. Damage to the skin and small blood vessels gradually leads to cell death. In turn, dead cells become prey for bacteria and sources of infection.

Anyone confined to a bed or a wheelchair for long periods of time is at risk of developing pressure sores. The danger increases with great limitation of movement and violation of sensations. Bed sores are more likely to form on areas of the body where there is more body pressure or constant friction against bedding (eg, elbows, knees, shoulder blades, back, and buttocks).

An early sign of superficial pressure sores is shiny, reddened skin on areas of the body that are under pressure. Later, small blisters or erosions appear on the reddened areas, eventually necrosis (death of tissue cells) develops, and ulcers form.

The first sign of the development of bedsores is the pallor of skin areas, followed by their redness, swelling and flaking of the epidermis. Then blisters and skin necrosis appear. In severe cases, not only soft tissues are subjected to necrosis, but also the periosteum and the surface layers of the bone substance. Accession of infection can lead to sepsis and be the cause of death of the patient.

Sometimes soft tissues are compressed when the patient's body rests against sanitary or medical equipment. Badly placed dressings, splints, catheters, bedpans can contribute to the formation of bedsores. Almost any hard object that presses against the skin can be dangerous if the patient cannot move normally. Items such as buttons, knots in clothing, pins, and other small objects in bed can, under the patient's body, create areas of high pressure where blood flow is blocked.

Pressure as well as shear forces are the most important reasons why circulation is blocked and pressure sores form as a result. Damaged skin and soft tissues are more than healthy, prone to the risk of bedsores in violation of normal blood circulation. Many causes can lead to skin damage.

When the outer layers of the skin are scratched or frayed, an abrasion occurs. Usually this phenomenon is accompanied by itching and scratching. Patients whose skin itches for any reason can also comb it. Sometimes the abrasion is so small that it is barely visible, but it can be dangerous because the surface of the skin is already damaged. You have all seen what happens to children's knees when they fall. The same thing happens to the patient in bed when he rests his elbows and heels on the surface of the bed, trying to move. He slides, rubbing his elbows and heels against the sheet in such a way that it turns out, as it were, a “burn” from friction. This also happens when an immobile patient is pulled across the bed, with the skin rubbing against the sheet. If the sheet is made of coarse linen and starched, then the likelihood of getting a "burn" from friction is even greater. The same motions that cause a friction "burn" can create shear forces that can damage the soft tissue under the skin if the tension is so strong that it tears the tissue.

Ordinary adhesive tape can be dangerous for patients' skin. When applied unevenly, the patch will stretch or compress the skin, forming folds. When the patch is removed from the surface of the skin, the top layer of the skin is torn off, making it thin and easily damaged. The skin of some patients is hypersensitive to the patch and thus may experience an allergic reaction.

Skin that is too dry can peel, peel, or crack, breaking the integrity of the inner layers. Bacteria can enter through the cracks and multiply on the surface of the skin and inside tissues.

Skin that is too wet also has less resistance to damage. Skin that is wet for too long becomes swollen, soft, and easily injured by scratching or rubbing. Patients who cannot control bladder or bowel activity need additional nursing care. It is important to prevent prolonged wetting of the skin, ensuring the change of clean bed linen. Excessive sweating in hot weather or at elevated body temperature is also a problem that needs to be addressed. Discharge from open wounds, sometimes from pressure sores themselves, can soften and inflame the surrounding skin.

Infection of the skin and soft tissues leads to their damage and affects deeper tissues. Dirty, too dry or too wet skin is especially prone to infection.

Medicines applied to the skin can often cause damage to the skin. Some of them, being strong chemicals, directly harm the skin; others cause an allergic reaction. Even soap used to wash the body can cause skin irritation and inflammation if it is too rough or not completely rinsed off.

Poor nutrition is detrimental to the health of any person. If the patient does not receive enough water, protein and other essential elements, including certain vitamins and minerals, then his tissues will not be able to resist the occurrence of damage and recover from them.

1.2 Types and stages of bedsores

Depending on the predominance of one of these factors, bedsores are divided into two groups: exogenous and endogenous. In the occurrence of exogenous bedsores, the main role is played by the factor of prolonged and intense compression of soft tissues. The weakening of the body in this type of bedsores only creates conditions under which bedsores develop faster and spread wider and deeper than in healthy individuals.

Exogenous bedsores are:

outdoor;

internal.

External exogenous bedsores occur when soft tissues are squeezed (especially if they do not contain muscles - for example, in the area of the ankles, calcaneal tubercle, condyles and trochanters of the thigh, olecranon, etc.), between the bone (usually a bone protrusion) and some or an external object (mattress surface, bandage, splint, etc.). In the vast majority of cases, such bedsores occur in operated patients who are in a forced position for a long time, as well as in trauma patients with an incorrectly applied plaster cast or splint, inaccurately fitted prosthesis, corset, medical orthopedic apparatus.

Ministry of Health of the Republic of Buryatia

State autonomous educational institution of secondary vocational education

Baikal Basic Medical College

Specialty "Medicine"

Qualification "Paramedic"

COURSE WORK

discipline: Care activities

Topic: Prevention of bedsores

Completed by: Romantseva A.

2nd year student, 121 groups

Leader: Rev. Ermakova N.I.

Selenginsk - 2014

Introduction

Chapter 1

1.1 Classification of bedsores

1.2 Stages of bedsores

Chapter 2

1 Locations of bedsores

2 Causes of bedsores

3 Risk factors for pressure ulcers

4 Clinical manifestations

5 Complications of bedsores

Chapter 3

1 Inspection and diagnosis of bedsores

2 Prevention of bedsores

3 Treatment of bedsores

Conclusion

Bibliography

Introduction

The relevance of this study is predetermined by the changes that are taking place in the modern world in general and the nursing system in particular. On the one hand, the need for new knowledge and skills in the care of bedsores is increasing, but on the other hand, despite the unfavorable situation against the backdrop of the economy, it remains indispensable to provide moral support to the patient and his relatives when it is really needed. In addition, with the undoubted importance of the precise implementation of medical prescriptions, the medical brother becomes a more active participant in the medical process, due to constant contact with the patient. These factors, interacting in a certain way, influence the personality, psychology and worldview of the nurse, her attitude to what is happening, and ultimately, the ability to work and the ability to perform her job duties.

The main purpose of this work is, based on various sources of information, to identify the main causes of pressure sores in patients and to find less painful ways to solve these problems:

· to reveal the concept of bedsores and identify the causes of their occurrence;

· characterize the stages of bedsores;

· consider measures to prevent bedsores;

· identify complications of bedsores;

The subject of the study is the care and prevention of bedsores in patients in the work of a medical brother.

The object of the study is the professional skills of medical workers in caring for patients.

Chapter 1

bedsores (decubiti) - ulcerative-necrotic and dystrophic changes in tissues that occur in areas of the body that are subjected to systematic pressure, or resulting from neurotrophic disorders in debilitated, long-term patients.

1.1 Classification of bedsores

There are exogenous and endogenous bedsores.

In the development of exogenous bedsores, the factor of intense long-term compression of soft tissues plays the main role. There are external and internal exogenous bedsores.

External bedsores often occur in places where there are no muscles between the skin under pressure and the underlying bone (for example, in the neck, shoulder blades, femoral condyles, olecranon, sacrum, etc.). As a rule, such bedsores are observed in operated or trauma patients who are in a forced position for a long time. The immediate causes of exogenous bedsores are incorrectly applied plaster casts or splints, ill-fitting prostheses, corsets and medical orthopedic devices, as well as folds in clothes and sheets, tight bandages, etc.

Internal exogenous bedsores are formed under rigid drains, catheters that stay in a wound, cavity or organ for a long time.

Endogenous bedsores develop with severe neurotrophic disorders and circulatory disorders. Conditionally allocate mixed and neurotrophic endogenous bedsores.

Mixed bedsores occur in debilitated malnourished patients who are unable to independently change the position of the body or limb. Prolonged immobility leads to impaired microcirculation, ischemia of the skin in the area of bone protrusions and the formation of bedsores.

Endogenous neurotrophic pressure ulcers occur in patients with damage to the spinal cord or major nerves, stroke, or brain tumor. In connection with the violation of innervation, sharp neurotrophic disorders develop in the tissues, including the skin. For the formation of neurotrophic bedsores, it turns out that the mass of one's own skin over bone protrusions (for example, over top anterior iliac spines, above the costal arches, etc.).

1.2 Stages of bedsores

Bedsores are usually divided into several stages depending on the severity of the disease. American specialists from NPUAP, who study pressure ulcers, propose to distinguish stages:

Stage I The initial stage of bedsores is characterized by the following features:

1.The patient's skin is intact (not damaged).

2.The skin appears red in people with fair skin tones. With a short press, it does not turn pale, as in healthy people.

.Individuals with dark skin may not have noticeable color changes. Sometimes the skin becomes ashy, bluish or purple.

.The site of a pressure sore may be painful, hard or soft, warm or cool compared to the surrounding skin.

Stage II. Pressure ulcers are open wounds:

.The outer layer of the skin (epidermis) and part of the inner layer (dermis) is damaged or completely lost.

2.A bedsore looks like a small deep pinkish-red wound. Wounds can be of different sizes.

.A pressure sore may also look like an intact or ruptured blister filled with fluid (exudate).

Stage III. A bedsore is a deep wound:

.Under the lost skin, a fatty layer is visible.

2.The wound is shaped like a deep crater.

.The bottom of the wound is sometimes filled with yellowish dead tissue.

.Damage can spread away from the primary wound.

Stage IV It is characterized by a large-scale loss of tissues:

.The wound affects muscles, tendons and bones.

Chapter 2

1 Locations of bedsores

Bedsores occur most commonly in the sacrum, shoulder blades, heels, knees, ribs, toes, greater trochanters of the femur, feet, ischium, iliac crests, and elbow joints. In world practice, there are also cases of localization of bedsores on the fingers, as well as on the head and ears; the skin (superficial pressure sore) and subcutaneous tissue with muscles (deep pressure sore, which is dangerous for the formation of an infected wound) are affected.

A bedsore on the skin can also occur from the pressure of a plaster cast in case of fractures or on the mucous membrane of the mouth - from the pressure of a denture, etc. The main reasons for the localization of bedsores are pressure and time. If the external pressure for a long time (more than two hours) is higher than the pressure inside the capillaries, then the formation of bedsores is almost inevitable.

Potential bedsores are all over bony protrusions on the body that are compressed when lying or sitting. In these places, the subcutaneous fat is the least pronounced, the pressure of the bone protrusions is most pronounced. If the patient lies on his back - these places are the sacrum, heels, ischial tubercles, elbows, shoulder blades, occiput. If on the side - on the side of the thigh (area of the greater trochanter), on the sides of the ankles and knees. If the patient lies on his stomach - the pubic area and cheekbones.

Common locations for pressure ulcers:

.Buttocks

2.Shoulders

.Back

.back of hands

.back of legs

2 Causes of bedsores

It is well known that the tissues of the human body function by obtaining the necessary nutrients from the blood. Blood vessels deliver blood to all organs and tissues of the human body, which innumerable permeate all human tissues and are soft elastic tubes. The smallest of them - capillaries - are especially important for normal tissue metabolism. The movement of fluid through such tubes is easy to slow down or completely stop by squeezing them. In any sitting or lying person, soft tissue compression and blood vessel compression occur, resulting in insufficient blood flow to the tissues. If this condition lasts more than 2 hours, then malnutrition (ischemia) occurs, and then necrosis (necrosis) of soft tissues. A bedsore develops. Therefore, we must remember that prolonged motionless lying or sitting is not safe!

The second reason why bedsores can form is, for example, when a patient is pulled along the bed, wet linen is pulled out from under him, and they try to push a vessel under him. At this time, there is a significant displacement of the surface layers of soft tissues in relation to the deeply located layers, as a result of which small blood vessels are torn, and the blood supply to these departments is disturbed. Similarly, bedsores can also form in weak recumbent patients who, without support in their legs, begin to slowly slide down a chair or bed from a sitting or half-sitting position, which is barely noticeable to the eye, but very noticeable for soft tissues.

The main causes of bedsores:

.Prolonged pressure. When the skin and soft tissues are squeezed between the bone and the surface of the chair (bed), the blood circulation in the tissues worsens. The cells do not have enough oxygen and nutrients, because of which they begin to die off - bedsores are formed.

2.Friction. When the patient changes body position, friction against the bed or other objects can damage the skin. This happens especially easily if the skin is extremely dry and sensitive.

.Muscle shift This slight shift can damage blood vessels and tissues, making the area more vulnerable to pressure sores.

3 Risk factors for pressure ulcers

Any person with limited mobility is at risk. Mobility disorders can occur with such diseases:

1.paralysis

2.General weakness

.Consequences of injuries

.Recovery after operations

.Prolonged stay in a coma

The main risk factors for pressure sores are:

.Age. Older people have more sensitive and insufficiently elastic skin. Their cells do not regenerate as quickly as in young ones. All this makes old people prone to bedsores.

2.Loss of sensation. Spinal cord injuries, neurodegenerative diseases, stroke, and other illnesses can impair sensation. The inability to feel discomfort favors the development of pressure sores.

.Loss of body weight. Weight loss is common with long-term severe illness. Muscular atrophy develops rapidly in people with paralysis. A smaller layer of tissue between the bones and skin is a greater likelihood of bedsores.

.Poor nutrition and lack of fluids. Adequate intake of fluids, proteins, fats, vitamins and minerals is essential for maintaining healthy skin.

.Urinary or fecal incontinence. Bladder and bowel problems can significantly increase the risk of pressure ulcers. This is due to the fact that the secretions accumulate in the perineum and under the buttocks, irritating the skin and favoring infections.

.Excessive dryness or moisture. Sweaty and damp skin is just as bad as dry and sensitive skin. To keep the skin healthy, you need regular proper care for bedridden patients.

.Diseases that disrupt blood circulation. Diabetes and vascular disease can interfere with blood flow to tissues, increasing the risk of pressure sores and infections.

.Smoking. Nicotine has a very bad effect on blood circulation, tobacco smoke reduces the amount of oxygen in the blood. Smokers are prone to developing severe bedsores, and their wounds heal slowly.

.Mental disorders. Patients with mental disabilities caused by illness, drugs, or injury may lose the ability to take care of themselves. They need special care to avoid bedsores.

.Muscle spasms. People with muscle spasms and involuntary movements are exposed to constant friction, so they develop pressure sores more often.

4 Clinical manifestations

Clinical manifestations of bedsores develop against the background of the main, often very serious disease and depend on the type of pathogenic microflora and the nature of necrosis. In stage I, mild local pain and a feeling of numbness are noted. If the spinal cord is damaged, areas of necrosis may appear within 20-24 hours; in other cases, the transition to stage II of the process is slower.

With the development of bedsores by the type of dry necrosis, the patient's condition is not noticeably aggravated, since intoxication is not pronounced.

The mummified area is limited to the demarcation line, since dry necrosis does not tend to spread. A different clinical picture is observed with the development of bedsores by the type of wet necrosis. A foul-smelling liquid is released from under the necrotic tissues, as a result of the rapid reproduction of the pyogenic and putrefactive flora, the purulent-necrotic process is rapidly spreading. Developed decubital gangrene causes purulent-resorptive fever and severe intoxication. There is a rise in body temperature to 39-40 °, depression of consciousness, delirium, chills, shallow breathing, tachycardia, lowering blood pressure, enlarged liver. Severe intoxication is accompanied by pyuria, proteinuria, progressive dysproteinemia and anemia. The blood shows leukocytosis with neutrophilia, an increase in ESR.

5 Complications

Bedsores often lead to complications

With proper and timely treatment, the risk of complications is low, but sometimes the following problems may occur:

1.Sepsis. This dangerous complication occurs when bacteria enter the bloodstream from the wound, spread throughout the body and cause foci of infection. Sepsis can lead to toxicity, organ failure, and death.

2.Cellulite. An acute infection of the subcutaneous tissue causes pain, redness, and swelling. Cellulitis leads to life-threatening complications, including sepsis and meningitis.

.Joint and bone infections. If the germs from the wound get deep enough, a bone infection (osteomyelitis) and damage to the articular cartilage can develop.

.Crayfish. In chronic, long-term wounds that do not heal, cancer can develop, which can be very aggressive and require urgent surgical treatment.

pressure sore clinical risk care

Chapter 3

1 Inspection and diagnostics

Careful examination of the skin should be an integral part of the daily care of the bedridden or wheelchair-bound patient. At the first signs of an early stage of bedsores, you need to see a doctor. Especially dangerous are signs of infection, such as fever, discharge or an unpleasant smell from the wound, redness and swelling of the surrounding tissues.

The doctor's diagnosis is as follows.

During the examination, the doctor:

1.Determines the exact size and depth of the wound.

2.Checks for bleeding, fluid, and dead tissue.

.Identifies a specific odor that may indicate an infection.

.Examines the skin around the wound for signs of infection.

.Checks other areas of the body for pressure sores.

.Makes an anamnesis from the following questions:

ü When did bedsores first appear?

ü How painful is the wound?

ü Have you had bedsores before?

ü If so, how were they treated and how did they end?

ü Who cares for the sick?

ü What other diseases does the patient suffer from?

ü What treatment is he receiving?

ü What is the patient's diet?

ü Does the patient change positions in bed, and how often?

ü How much fluid does the patient drink daily?

Based on the examination and the compiled anamnesis, the doctor directs for tests:

2.Culture to detect bacterial or fungal infection in a wound that is not responding to treatment or has already reached stage IV.

.Microscopy to check for malignant (cancerous) cells if there is a chronic, refractory wound.

2 Prevention of bedsores

Treatment and prevention of bedsores are inextricably linked with a whole range of measures to care for a sick person.

Material costs for the prevention of bedsores are always less than for their treatment.

The organization of care and observation of the patient should be carried out by one person. He may have assistants - specialists with whom you can consult; but the one who organizes the care and has the most opportunity to observe the sick person should make the final decision.

Patients using a wheelchair, bedridden patients, patients suffering from partial immobility (of body parts), urinary and / or fecal incontinence, malnourished patients, obese patients suffering from diabetes mellitus, consequences of a stroke.

Prevention principles:

.Reducing pressure, friction or shear. You need a soft but firm mattress. A foam mattress is suitable for this, the thickness of which should be at least 15 cm. The bed should be even without tubercles and pits. You can purchase a special anti-decubitus mattress, but it is not a panacea for bedsores, with a lack of other measures, a patient lying on it can still form bedsores. Examine the skin daily, especially in places of bony protrusions, since it is there that bedsores form. It is necessary to frequently change the position of the patient's body so that the skin experiences minimal friction and soft tissues minimal displacement. This must be done at least every 2-3 hours, including at night. Rollers are additionally placed under the places of bone protrusions, for example, soft pillows made of feather or foam rubber. Under the fixed limbs, bags filled with round grains, such as millet, can be sewn. A rubber circle is placed under the sacrum. The point of using a variety of rollers and anti-decubitus mattresses is that they increase the area of contact between the body and the surface on which the patient lies, which means that pressure on each part of the body decreases, circulatory disorders decrease, and thus the risk of pressure sores decreases. Do not drag or pull out underwear from under the patient, especially if it is wet. Do not push a ship under it. For all this, there are simple tricks, the main meaning of which is that the patient must first be lifted, and only then moved or put something under him. Do not leave the patient in an uncomfortable position, and do not try to seat or give them a semi-sitting position for weak patients, as their muscle activity is not enough to keep them in this position, and they begin to slide. Provide such patients with a support (any device for support) in the legs.

2.Complete nutrition. Drinking and eating should be complete, subject to restrictions, if any. Food should contain at least 20% protein, foods that contain many trace elements - iron and zinc, as well as vitamin C. Use fermented milk products, greens, vegetables, fruits. For seriously ill patients, meat is a difficult food. Use chicken broth, fish, beans, cereals and dairy products to cover your protein needs. Drinking at least 1.5 liters, if there are no restrictions. Do not use sweet and carbonated drinks, as well as freeze-dried products, that is, quick preparation from solids by dissolving in water.

.Reducing skin irritation. Lay soft linen; make sure that there are no rough seams, buttons, patches on the linen; straighten the bed regularly and often so that there are no folds and small objects under the patient. Use low-allergenic, proven skin care products. Avoid substances that are bright in color and strong in smell. To toilet the perineum more often, as particles of feces and urine are strong irritants. Cut your nails short for yourself and the patient: for yourself - so as not to accidentally scratch the patient, and for the patient - so that he does not comb the skin, since the squeezed areas itch when lying or sitting for a long time. Make sure that the patient is dressed and covered with a blanket according to the temperature conditions of the room. When the patient overheats, sweating increases and the risk of developing pressure sores increases.

.Skin care rules The rules are quite simple: avoid skin contamination, excessive dryness and moisture; use ordinary water, soap, a washcloth made of cotton fabric or a natural sponge, nourishing and moisturizing creams, drying ointments, powder. Carefully observe the skin, and it will become clear to you at what point what to apply. The general rule is: wet skin should be dried, and dry skin should be moisturized. Do not use antibacterial soap, as beneficial microorganisms are destroyed along with harmful bacteria; the skin after stopping the use of such soap becomes incapable of resisting even a minor infection. Alcohol-based products such as lotions and camphor alcohol should only be used on patients with oily skin. Do not rub the skin in places of compression when washing. Use soft sponges and use them very delicately so as not to injure the upper layers of the skin. When drying the skin, do not wipe it, but soak it with a towel. In no case do not massage the reddened areas of the skin, but a light regular massage around these places is highly desirable. Be sure to arrange air baths for the skin.

.Personal hygiene. The condition of the skin is significantly affected by moisture, mainly urine and sweat. For urinary incontinence, it is better to use pads or diapers, although for some patients it is enough just to give the vessel more often. For lack of funds for linings and diapers, try to use linen diapers. With urinary incontinence in men, you can use a special urinal system (urinal). Increased sweating is observed in temperature patients. In order to reduce sweating, it is necessary, first of all, to treat the underlying disease. For wiping the patient, it is better to use not soap and water, but a weak solution of vinegar (1 tablespoon of table vinegar per 1 glass of water).

3 Treatment of bedsores

Treatment must be comprehensive. It consists of three main components: cessation of constant pressure on the pressure sore area, local treatment and treatment of the underlying disease. When the color of the skin changes, any pressure on this area is stopped by changing the position of the body, placing an inflatable rubber circle, the skin is treated with camphor alcohol, washed with cold water.

When areas of necrosis occur, topical treatment is aimed at drying the necrotic tissue and preventing the transition from dry necrosis to wet necrosis. For this purpose, a 1% solution of potassium permanganate, a 0.5% aqueous-alcoholic solution of chlorhexidine, a 1% solution of brilliant green are used. The area is closed with a dry aseptic bandage. At this stage, the use of important and ointment dressings is unacceptable.

After the scab is rejected and the wound is filled with granulations, ointment dressings are used or, according to indications, autodermoplasty is performed.

At P., proceeding according to the type of wet necrosis, the main goal of local treatment is to achieve the fastest possible rejection of necrotic tissues. The most effective in this regard are proteolytic enzymes, especially immobilized proteases of prolonged action and ointments on a hydrophilic basis (levosin, levomekol, dioxicol). Bandages with hypertonic solution can also be used. If necessary, perform necrectomy, which significantly reduces the time of treatment of bedsores. With decubital gangrene and other purulent complications, their surgical treatment is indicated - necrectomy, opening of phlegmon, purulent streaks, etc., followed by drainage and treatment in accordance with the principles of treatment of purulent wounds. Various methods of plastic closure of defects formed after excision of necrotic tissues and ulcerative surface of the bedsore are used. To close the wound, local tissues or free autodermoplasty with a split skin flap are used. Skin plasty is also carried out for large granulating wounds at the final stage of local treatment.

In addition to surgical methods, UHF therapy, antibiotics, air ionization, darsonvalization, etc. are prescribed locally, depending on the stage of the purulent-necrotic and wound process. Antibacterial therapy is carried out taking into account the sensitivity of pathogenic microflora to it.

In addition to the local, intensive treatment of the underlying disease is necessary, as well as detoxification and stimulating therapy. For this purpose, blood products are transfused, solutions of blood substitutes (Hemodez, reopoliglyukin), immune preparations are used, vitamin therapy is carried out, and therapeutic high-calorie nutrition is prescribed.

The prognosis for external exogenous bedsores is favorable, since after the pressure on the tissues and appropriate therapy are stopped, it is possible to achieve a cure relatively quickly.

More dangerous are internal exogenous bedsores due to the possibility of damage to the walls of large vessels, hollow organs with the occurrence of severe complications. The prognosis for endogenous bedsores is usually serious, since the patient's condition is largely aggravated by the underlying disease and the addition of a purulent-necrotic process reduces the chances of a favorable outcome.

Pressure ulcers in the first or second stage usually respond well to treatment and are completely cured in a few weeks or months with conservative treatment and proper care. Running wounds in the third and fourth stages are difficult to treat. In patients at the end stage of a fatal disease, treatment for pressure ulcers is directed primarily at relieving pain rather than completely healing the wound.

Specialists who should take part in the complex treatment of bedsores:

.A doctor who specializes in treating wounds (surgeon).

2.Medical staff who regularly treat wounds and care for the bedridden patient, as well as educate his family members.

.A specialist in physiotherapy who can help the patient at least partially restore mobility.

.A nutritionist who must develop an optimal diet for the patient.

.Neurosurgeon, orthopedic surgeon and plastic surgeon, whose assistance may be needed in tissue repair after pressure ulcers.

.Social workers who must provide the patient and his family members with psychological and, if necessary, material assistance.

Treatment to relieve pressure on tissues:

.Change in body position. A bedridden patient must regularly change position, and he must lie correctly. Wheelchair users should change positions every 15 to 20 minutes, either on their own or with assistance. The correct body positions in one case or another must be shown by medical personnel.

2.supporting surfaces. Special supports, pillows and mattresses will help the patient to maintain the body in the correct position, as well as relieve pressure on dangerous areas.

Treatment aimed at removing damaged tissue from the wound:

.Surgical cleaning of the wound consists in cutting out dead tissue.

2.Mechanical cleaning of the wound. Many methods are used, such as pressure irrigation, special baths.

.Enzymatic cleaning. The method is based on the use of natural enzymes that break down dead tissues.

Other treatments for pressure ulcers include:

.Pain relief. Inside, patients may be prescribed painkillers from the group of non-steroidal anti-inflammatory drugs, or NSAIDs. Among them are ibuprofen, naproxen, diclofenac, nimesulide and others. Topically, you can apply sprays that contain lidocaine, which is especially necessary before procedures.

2.Antibiotics. Pressure ulcers that are infected and difficult to treat can be treated with antibiotics (both internally and externally).

.Wound healing stimulants. Among such funds, the famous preparations Actovegin and Solcoseryl can be noted. They stimulate reparative processes in tissues. Used in the form of ointments, gels, creams.

.Healthy diet. Proper nutrition and sufficient fluid intake promote wound healing. The diet of the patient should be rich in proteins, vitamins and minerals. The doctor may additionally prescribe multivitamin complexes with a high content of vitamin C and zinc.

.Relief of muscle spasms. Muscle relaxants such as diazepam (Valium), tizanidine, dantrolene, and baclofen can relieve spasms. This will prevent worsening in patients who damage their wounds with muscle twitches.

Conclusion

Bedsores - necrosis of the skin and soft tissues - occur as a result of prolonged squeezing. Bedsores most often appear on those areas of the skin that cover protruding bones - shoulders, ankles, buttocks, etc. The greatest risk of developing bedsores is in people who, as a result of the disease, are bedridden for a long time and rarely change body position. Bed sores develop quickly and are sometimes difficult to treat.

The results strongly suggest that measurable significant improvements can be achieved with quality patient care programs. Equally important was the possibility of exchange of experience between doctors and specialists within the framework of this program. As a result, in 48 medical institutions out of 150, not a single new case of pressure ulcers in bedridden patients was noted! This is an impressive result.

The main methods that have made it possible to achieve such impressive results are simple: a complete assessment of the patient's skin condition every 8 hours, an assessment of the risk of violation of the skin, the application of preventive measures, such as the correct position of the patient's body in bed or in a chair, and the use of special devices. Also, special attention was paid to the hygiene of the skin of the areas of the body most at risk of developing bedsores.

List of used literature

1.Bazilevskaya Z.V. Prevention and treatment of diligent, M., 1972;

2.Popkirov S. Purulent-septic surgery, trans. from Bulgarian, Sofia, 1977;

.Wounds and wound infection, ed. M.I. Kuzin and B.M. Kostyuchenok, M., 1981;

.Struchkov V.I., Gostishchev Yu.V. and Struchkov Yu.V. Guide to purulent surgery, M., 1984.

5.Bakulev A.N., Brusilovsky L.Ya., Timakov V.D., Shabanov A.N. Big Medical Encyclopedia M., 1959.

6.Khlyabich G., Zhdanov V. AIDS: to know and fight. medical newspaper April 22, 1987

.Kudryavtseva E., AIDS from 1981 to Science and life No. 10, 1987

.V.M. Pokrovsky V.M., Korotko G.F., Human Physiology M, 1992.

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