Decubitis ulcers, more commonly known as bedsores, is an “open sore caused by pressure, friction, and moisture” (Radomski & Trombly Latham, 2014, pp. 696). There are three main ways that these cores occur: pressure, friction, and shear. When constant pressure is applied to any part of the body, blood flow to that region will decrease, and therefore decreasing the amount of oxygen that the tissue gets. If an individual has limited mobility, the constant pressure to areas of the body that lack muscle or fat could cause the tissues to begin to die. Skin rubbing against clothing or bedding causes friction, which leads vulnerable skin to injury. Shear occurs when the direction of two surfaces are moving in an opposite direction. Those who are most at risk for developing bedsores due to pressure, friction, and shear are those who are immobile, those with decreased sensory perception, those who are poorly hydrated or malnourished, and those who have conditions that affect their blood circulation. If an individual is immobile, they will be unable to adjust themselves, and they must rely on others to move them at designated periods of time to prevent bedsores. Individuals who lack sensory perception have an inability to feel pain and will be unaware of any discomfort they may feel to change positions. Those who are malnourished or dehydrated lack proper nutrients to preserve healthy skin and making it more susceptible to breakdown. Any condition in which there are compromises to an individual’s circulation will also put someone at more of a risk of developing bedsores due to the increased risk of tissue injury. Common sites of pressure sores varied based on where the pressure is distributed. For an individual in a wheelchair, these ulcers are common at the tailbone or buttocks, shoulder blades, spine, or on the posterior surface of the arms and legs. An individual in a bed could commonly have them on the back of the head, shoulder blades, hips, tailbone, or on the heels or ankles. Common symptoms of decubitis ulcers are: changes in skin color, swelling, pus-like draining, inconsistent temperatures of the skin, and tender sites (Mayo Clinic Staff, 2017).
There are several stages that decubitis gets classified into which are based on many characteristics. Stage 1 is a non-blanchable erythema of intact skin. This stage is characterized by discoloration of skin, temperature changes, and changes in sensation; however, the discoloration is not markedly different or colorful. Stage 2 is partial-thickness skin loss with exposed dermis. This stage is characterized by an intact or ruptured blister, pink or red in appearance, and moist. Stage 3 is full-thickness skin loss, which is characterized by fat visible in the ulcer, slough (yellow devitalized tissue) in the wound, and the depth of damage varied depending on where the ulcer has formed. Stage 4 is full-thickness skin and tissue loss. This stage is characterized by visible muscle, tissue, ligament, cartilage, or even bone in the ulcer. If slough or eschar is blocking the view of the ulcer, it is characterized as unstageable. An unstageable pressure injury is a classification where the damage cannot be identified (“NPUAP pressure injury stages”, 2016). Complications with decubitis can be life threatening, and it is estimated that about 60,000 people die each year due to these complications. Some complications are cellulitis, infections, cancer, and sepsis.
Treatment for decubitis focuses on lessening the amount of pressure on the area of the body, caring for wounds, and pain management. An interdisciplinary team will work to reposition the patient to shift the pressure so that it is not all on the wound. Caring for pressure ulcers is important to prevent infection and further complications for the patient. Depending on the severity of the ulcer, debridement may be necessary to clear the wound of damaged tissue, slough, or eschar. Team members will clean and bandage the wound to speed the healing process and keep it covered to prevent infection. In more severe cases of decubitis, surgery may be required to repair affected muscle, and cushion the bone (Mayo Clinic Staff, 2017).
Prevention of these pressure wounds is vital and begins with education. Occupational therapists can play an important role in educating individuals on the risk factors as well as the early detection of such injuries. It is important for individuals or caregivers to check the body daily paying close attention to the: heels, ankles, knees, hips, spine, tailbone area, elbows, shoulders, shoulder blades, ears and back of the head (Martin, 2016). Ensuring proper self-care is also very important for prevention of bedsores. Individuals should treat skin gently when washing as well as moisturize to keep skin intact and hydrated (Martin, 2016). Proper hydration and nutrition is also important for keeping the body and the skin healthy which further helps to prevent the breakdown of skin (Martin, 2016). When dressing, one should avoid wearing clothes with thick seams, buttons or zippers that could press on the skin as well as clothes that are too tight. Wearing these types of clothing could increase the risk of developing a pressure sore. Individuals who use wheelchairs should make sure they are using a wheelchair that fits properly. Checking the fit at least once every year can help to prevent individuals from using wheelchairs that ultimately could lead to a decubitus ulcer (Martin, 2016). These individuals must also be sure that they transfer to and from their wheelchair without dragging themselves as this could cause injury to the skin.
The other main component of prevention is reduction of pressure on the body. When laying in bed individuals should reduce pressure by putting pillows or foam underneath high risk areas such as the heels, tailbone, shoulders/shoulder blades and elbows (Martin, 2016). It also is important to change positions every 1 to 2 hours prevent pressure in any one area (Martin, 2016). Individuals in wheelchairs should be educated and ways they can shift their weight to maintain blood flow and reduce pressure (Martin, 2016). Occupational therapists can also make recommendations for the use of pressure relieving cushions, mattresses and other equipment (Lyon, 2017). Overall, there are many ways to prevent the occurrence of a decubitus ulcers or pressure sores and it is extremely important to practice these prevention tips.
Necrotizing fasciitis is a rare, rapidly progressive bacterial skin infection that kills the soft tissues of the body, sometimes referred to as a “flesh-eating infection” (Centers for Disease Control and Prevention [CDC], 2017). The majority of the cases of necrotizing fasciitis occur randomly, but the most common way of getting this infection occurs when the bacteria enters the body through a break in the skin, such as a cut, burn, or puncture wound. This disease spreads rather quickly and can be deadly within a small period of time. The CDC indicates that people at risk include those with a compromised immune system, such as those with cancer, and those who have recently undergone a surgical procedure (2017). Some symptoms include pain or soreness, red/purple skin, blisters, chills, and vomiting. Good wound care and proper hygiene are the best ways to prevent this skin infection (CDC, 2017).
This disease is quite rare, but many different forms of bacteria can cause it, such as group A Streptococcus (group A strep), Klebsiella, Clostridium, Escherichia coli, Staphylococcus aureus, and Aeromonas hydrophila, with group A strep being the most common cause (CDC, 2017). This monomicrobial infection is often accompanied by an underlying cause, such as diabetes or atherosclerotic vascular disease (Edlich, 2017). Normally, an infection caused by group A strep is rather mild and can be treated quite simply. However, in the case of necrotizing fasciitis, the bacteria spreads rapidly as soon as it enters the body. It invades the fascia, or connective tissue, that encompasses the muscle, fat, nerves, and blood vessels located in the body (CDC, 2017). It can also harm the tissue that surrounds the fascia. Toxins that are made by the bacteria are released, which damage the tissue and eventually cause it to die. If the infection gets to this point, those affected may lose limbs or even die (CDC, 2017).
According to the CDC, proper treatment includes things such as an accurate and timely diagnosis, rapid treatment using antibiotics to kill the bacteria in the body, and in some cases, surgery (2017). Strong antibiotics given through an IV is the most important step in treating the infection (CDC, 2017). If the toxins released by the infection destroy the tissue and reduce the blood flow, the antibiotics might not reach all of the infected and dying areas. In this case, surgery can be used to remove the dead tissue and stop the infection from spreading any further (CDC, 2017).
The reason the anterior thigh is an ideal breeding ground for necrotizing fasciitis, is because the the speed in which the bacteria multiplies is directly proportional to to the thickness of subcutaneous layer. Since, the thigh has more subcutaneous fat than other parts of the body the bacteria likes to breed and multiply there. The infection caused by the bacteria begins by infecting the superficial fascia. Enzymes and proteins released by the responsible organisms cause necrosis of fascial layers. Horizontal spread of infection may not be clinically apparent on the skin surface and hence diagnosis may be delayed. “Infection then spreads vertically up into the skin and down into deeper structures. Thrombosis occludes the arteries and veins leading to ischaemia and necrosis of the tissues” (Ngan, 2003, p.2). Hence, why the anterior thigh is an ideal breeding ground for the bacteria that causes necrotizing fasciitis. The anterior thigh contains thick layers of the fat and superficial fascia; and it is more likely to have a cut on one’s leg than any other part of their body. Once the bacteria enters the open wound the infection has already started, as the infection travels deeper than the subcutaneous fascia and fat the bacteria begin to spread horizontally and vertically from the wound infecting the surrounding skin, fascia, and fat. As the infection continues to spread the bacteria goes deeper into arteries and veins, which leads to the bacteria to infect the bloodstream cutting off blood supply to that part of the body, thus causing necrosis and ischemia of the body part. Due, to the large artery and vein that runs in the anterior thigh (femoral artery and vein), which supplies the entire leg (it splits and is renamed, but is essentially the same artery and vein), the bacteria can travel vertically throughout the entire leg and infect more of the leg leading to full amputation because the infection can spread very quickly.
While it is rare for necrotizing fasciitis to be passed onto one another, cases can happen if a health care provider, who has open cuts, wounds, or sores, has the bacteria enter the body through the breakdown in their own skin (including cuts, scrapes, burns, insect bites, or puncture wounds). Thus, all healthcare providers should utilize the universal precautions at all times when touching, debriding, cleaning, irrigating, and changing gauze, near the infected wound. The universal precautions include: washing hands coming in and out of treatment, wearing gloves, wearing a mask or protective eyewear if any pus has a way of coming in contact with the mouth or eye of the health care practitioner. The CDC recommends that “any hospital personnel with open wounds or cuts themselves, or respiratory illness, should not make contact with patients with [necrotizing fasciitis] to avoid infecting their own wounds” (Center for Disease Control and Prevention, 2017, p.1).