Decubitus – the necrosis of soft fabrics arising owing to violation of their food and long pressure upon a certain area of a body. Development of decubituses is promoted by limited mobility of the patient, insufficient leaving, and also violations of sensitivity and traffic. Decubituses usually arise in places of a prileganiye of bone ledges to skin (a sacrum, heels, shovels etc.). Defeat can be both superficial, and deep (with necrosis of muscles and sinews). Tactics of treatment of decubitus depends on depth and a stage of a necrosis. At superficial decubituses bandagings are carried out, at deep excision of the become lifeless fabrics is necessary. Treatment represents a long, complex challenge therefore in the course of patient care special attention has to be paid to preventive actions for the prevention of development of decubituses.
Decubitus – the necrosis of fabrics arising owing to long pressure in combination with violation of an innervation and blood circulation on a certain part of the body. Develops at the weakened bed patients. Besides, decubitus can develop at patients with changes owing to pressure of too hard or uneven plaster bandage, and also at people with dentures (at its bad adjustment).
The probability of development of decubitus first of all depends on two factors: quality of care and disease severity. In certain cases it is rather difficult to avoid emergence of decubituses and it is necessary to apply the whole arsenal of special means to their prevention: the antidecubital mattresses special the absorbing diapers, circles enclosed under certain parts of the body etc.
In modern traumatology and surgery classification of decubituses taking into account severity enjoys the greatest popularity:
- I stage of decubitus. Integrity of integuments is not broken. Reddening, a tsianotichnost or a crimson shade of skin is noted. Skin can look angry. Sometimes patients complain of morbidity or hypersensibility in the field of the formed decubitus.
- II stage of decubitus. There is a superficial wound with injury of epidermis and speak rapidly terms. Decubitus can represent a bubble with liquid or the red-pink, edematous, reminding an ulcer wound.
- III stage of decubitus. The necrosis extends to all depth terms and takes hypodermic fatty cellulose. At the same time the fastion and the subject bodies and fabrics remain intact. Visually decubitus in the form of the crateriform wound with a bottom from the yellowish become lifeless fabric comes to light.
- IV stage of decubitus. Extensive, deep decubitus. Necrotic processes extend to sinews, muscles and bones which can stand in a wound. The bottom of decubitus is filled with the become lifeless dark fabric.
Besides, there is a classification of decubituses taking into account the amount of defeat: small decubitus (with a diameter up to 5 cm), average decubitus (from 5 to 10 cm), big decubitus (from 10 to 15 cm) and huge decubitus (more than 15 cm). Separately allocate a svishchevy form of decubituses at which in soft fabrics there is a big cavity which is reported with the external environment through a small opening on skin (fistula). The cavity can be at considerable distance from a wound. At the same time separated "passes" through svishchevy the course, is frequent – curved, thin and twisting. At a svishchevy form of decubituses osteomyelitis of the subject bone is often observed.
The sdavleniye of fabrics between a bone and the firm surface which is outside is the main reason for developing of decubitus. Soft fabrics are squeezed between a bone and a bed or a bone and a wheelchair that leads to violation of blood circulation in small vessels. To cages of the squeezed area oxygen and nutrients ceases to arrive, as a result the site of fabric grows stiff and perishes.
Friction and sliding become the additional reasons of injury of skin to typical places of formation of decubituses. Friction about sheets or clothes arises when the patient independently changes a pose, or it is overturned or replaced by family members or medical workers. Sliding is promoted by too high raising of the head end of a bed at which the patient slides off down, and also attempt to keep in a sitting or semi-sitting position without due support. In risk group of developing of decubituses all people with limited mobility which can arise owing to belong:
- Diseases or injuries at which the bed rest or use of a wheelchair is necessary.
- Weakness and general feeling sick.
Treat number of other factors increasing risk of developing of decubituses:
- Deterioration in sensitivity owing to neurologic diseases, injuries of a spinal cord etc. At such states patients do not feel pain and the discomfort testifying to a sdavleniye of soft fabrics. Decubituses at patients with paralyzes are inclined to a long, persistent current and can arise even in atypical places (for example, owing to pressure of edge of footwear).
- Advanced age. With age skin becomes thinner, becomes thinner, dry and less elastic. Its recovery abilities decrease, and the probability of development of decubituses increases.
- Bad food and lack of liquid. Because of shortage of liquid and nutrients the condition of skin is broken that creates prerequisites for developing of decubituses.
- Loss of weight and muscular atrophy. Muscles and fatty tissue are natural layers between bone ledges and skin. At their reduction skin with a pressure is exposed to the increased loadings. Therefore decubituses are often formed at the exhausted patients.
- Too moist or too dry skin. Skin becomes dry at temperature increase, and damp – at the strengthened sweating which can be caused both by a disease, and an excessive overheat of the patient (too warm blanket, too high temperature indoors).
- Incontience of urine or calla. At the patients who are not controlling the bladder, skin often happens damp that does it to more vulnerable to formation of decubituses. And the bacteria which are present at kalovy masses can promote infection of decubituses and become the reason of development of heavy local complications.
- The diseases causing blood circulation violations (the diabetes obliterating endarteriit, sharp occlusion of vessels, the obliterating atherosclerosis).
- Muscular spasms. At the involuntary movements skin constantly suffers from friction about sheets, clothes and other surfaces.
- Consciousness violations. Patients cannot adequately estimate the condition and abstain from the actions provoking formation of decubituses or to perform the operations interfering their emergence.
- Smoking. Nicotine narrows vessels that leads to deterioration in blood supply. Besides, smokers suffer from a chronic lack of oxygen. All this becomes the reason of deterioration and delay of processes of healing of any wounds, including – and decubituses.
At the patients lying on a back, decubituses most often develop in areas of a sacrum. Perhaps also formation of decubituses in shovels, heels and a nape. At situation in a bed on one side decubituses arise in the field of a big spit of a femur, auricles, temples, the external surface of a shoulder, a knee and an ankle joint. If the patient lies on a stomach, decubitus can be formed in wings of podvzdoshny bones and on the forward surface of knee joints. At the people using a wheelchair, decubituses most often arise in the field of a sacrum, buttocks, a backbone, shovels, and also the back surface of hands and legs – in places where extremities lean against a chair.
The diagnosis of decubitus is exposed on the basis of a typical clinical picture and localization of damage. Special methods of diagnostics are not required. It is necessary to consider that at initial stages decubituses quite often happen painless or almost painless, the therefore all weakened, inactive patients need to be examined regularly, paying special attention to "risk zones" - to places of a prileganiye of bone ledges. At suppuration of decubitus the material intake for definition of the activator and definition of its resistance to various antibiotics can be required. Differential diagnosis of decubitus with skin cancer is in some cases necessary. The diagnosis is specified on the basis of a biopsy.
The heaviest complication of decubitus is sepsis – a life-threatening state at which bacteria with current of blood extend on an organism that can become the reason of polyorgan insufficiency and the death of the patient. Besides, decubitus can lead to development of phlegmon, purulent arthritis, contact osteomyelitis of the subject bone and a wound miaz (a wound infektation larvae of insects). At fusion of walls of vessels perhaps arozivny bleeding. In some cases in the field of chronic, it is long not healing decubitus skin cancer can develop.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Treatment of all decubituses, even small and superficial, has to be carried out with participation of the doctor. Self-treatment is inadmissible as at such approach perhaps further progressing of decubitus and development of heavy complications. Is among the basic principles of treatment of decubituses:
- Restoration of a blood-groove in the damaged area.
- The actions promoting rejection of necrotic masses.
- The actions promoting healing of a wound.
In the field of decubitus take special measures of prevention about which it will be told below for restoration of a blood-groove. For stimulation of rejection of necrotic masses use special medicines (a klostridiopeptidaz + chloramphenicol). In need of the preprocessing course sites of a necrosis delete by means of special tools.
After the wound is completely cleared of necrotic fabrics, carry out bandagings with alginates (special powder or napkins for filling of wounds), apply hydrocolloidal bandages and bandages with wound healing medicines. At a decubitus complication a bacterial infection apply local antiseptic and antibacterial means. To elderly patients and patients with heavy decubituses carry out antibiotic treatment. If after decubitus extensive defect was formed, skin plasticity can be required.
- Daily check of skin is compulsory procedure which has to be carried out at care of all heavy patients and disabled people. It is necessary to pay special attention to areas of bone ledges and a zone of risk of development of decubituses.
- For prevention of decubituses it is necessary to change each 2-3 hours position of the patient in a bed, to use special devices (rubber rings etc.) and antidecubital mattresses. All movements of the patient have to be carried out with the maximum care so that not to allow friction or stretching of skin.
- It is necessary to use soft bed linen and clothes from natural materials. It is desirable that on clothes there were no buttons, fasteners and other elements capable to create the center of elevated pressure on skin.
- It is necessary to maintain indoors comfortable temperature – not too low that the patient did not catch a cold, and not too high to avoid excessive sweating and formation of an intertrigo which in the subsequent can turn into decubituses.
- Bed linen has to change, be in due time dry and pure. If necessary it is necessary to use the special hygienic means (absorbing diapers, pampers, laying etc.).
Skin of bed patients becomes thin and very vulnerable to damages therefore care of it has to be careful, delicate. It is undesirable to use silnopakhnushchy and alcohol-containing cosmetics which can cause an allergy and irritation of skin. It is preferable to apply the special sparing hygienic means. It is necessary to watch that the patient's skin always remained dry and pure: to wipe it with a soft towel at the increased sweating, as fast as possible to delete natural allocations (kcal, I wet) from skin, to carry out hygiene of intimate zones after each defecation and an urination.
Change of bed linen needs to be carried out with use of special receptions, overturning the patient and rolling it on pure sheets, but without pulling out from under it linen at all. It is also necessary to stimulate the patient to the movement and to watch that its food was moderate, balanced, rich with mineral substances and vitamins, but rather noncaloric as because of small mobility the number of necessary calories in such cases decreases.