The stark reality for the bedridden, or for those who have limited mobility, is that pressure sores are often a fact of life. Caring for these, or for those returning home after surgery or for diabetics who are prone to wounds that are difficult to heal, is an important part of home care. Both visiting nurses and family members often end up sharing this responsibility.
“Pressure wounds are the most common type of wounds we see,” says Dr. Elin Kropp, a regional hospice medical director for Visiting Nurse Services of New York (VNSNY.) “It is recommended that a patient be turned and repositioned every two hours, or the skin will break down.”
Pillows can also be used to relieve pressure at bony prominences.
Pressure wounds, also known as decubitus ulcers or bed sores, occur mainly on the foot, the heel and the sacrum (backside). Some patients who have lost feeling in their extremities, such as paraplegics and diabetics, may develop pressure wounds without knowing it.
“In areas where the fat pad is thin, and the patient’s intake of protein and collagen production are reduced, constant pressure starts to break down the skin,” says VNSNY’s Dr. Mitchell Chandler.
The best treatment is prevention, adds Dr. Kropp. “Once it starts, it’s hard to reverse.”
There are now alternating pressure air mattress pads that are programmed to vary which parts of them are most inflated. The constantly varying firmness simulates moving a patient around. A moist, sterile environment is best for open wound healing.
Both doctors agree that wounds need to be managed at least every three days by skilled nurses and educated family members in a team approach. Home is actually a better setting in terms of preventing pressure wounds and new infections. However, it’s uncommon for family members to learn how to turn and reposition patients before leaving the hospital. Thus, when they get home, caregivers may not be aware of a key part of the care needed.
VNSNY nurses sometimes take cell phone photos of wounds (with consent) and share them with specialists on a secure server. Feedback comes within 24 hours. The images are secure and are protected by the patient privacy act, or HIPA. With 30,000 patients in the area, the technology speeds things up. And time is of the essence in wound care.
Dr. Chandler points out that with the rise of laparoscopic (keyhole) surgery, many post-surgical wounds are smaller than they used to be. “The likelihood of getting an infection after a laparoscopic cholecystectomy (gall bladder removal), for instance, is less than after an open cholecystectomy because the surface area of the wound is less,” he says.
Technology is advancing quickly in wound care. For example, negative pressure wound therapy, or vacuum-assisted closure (VAC) applies localized negative pressure to seal the wound, remove fluid, increase blood flow and increase the growth of healthy tissue.
Hyperbaric oxygen chambers — oxygen tents, of the sort used by the singer Michael Jackson, in the belief it would keep him young — are available and can speed up wound healing Those with diabetes-related wounds, burns, soft tissue infections and skin grafts can especially benefit from this treatment which increases oxygen to the wound at a higher pressure. The number of treatments depends on the extent of the wound and how well it responds to therapy.
And of course, you are what you eat.
“Wounds heal better with high-protein diets,” says VNSNY home nurse Edward Moriarty. “Not high carb diets. Too much sugar doesn’t do us any good.”