Bed Sores - prevention and care

Another article by our friend and client Lisa Browder. Lisa is a clinical aromatherapist in hospice. She is the Nevada Director for the National Association for Holistic Aromatherapy (NAHA) and has been a speaker at conferences for the National Hospice & Palliative Care Association, California Hospice and Palliative Care Association and the Association for Professionals in Infection Control.


Decubitus ulcers, also known as “pressure sores” or “bed sores,” are a constant concern in both hospice and nursing homes.  They occur when there is pressure on the skin that covers any bony prominence, and that not only includes common areas like the sacrum, coccyx and spine, but also elbows, heels, knees, hips, shoulders – even backs of ears and the bridge of the nose where an oxygen mask might be sitting.

Preventing their development is clearly the goal but that can be devilishly difficult since it takes as little as two hours for a bed sore to develop. And when the body’s capacity to heal has begun to diminish - meaning the heart is no longer strong enough to pump an adequate amount of blood (and thus nourishing red blood cells) to the damaged skin to help with wound healing and tissue reparation - it may not be possible to prevent a progression to a Stage IV decubitus ulcer. That doesn’t mean there aren’t things you can do to help.

Stage I pressure sores are characterized by a redness that doesn’t blanch when touched and this is the point when frequent repositioning of the patient may be most helpful. It’s also a good time to use a combination of skin replenishing fixed oils like Calendula (Calendula officinalis), Tamanu (Calophyllum inophyllum), Argan (Argana spinosa), Avocado (Persea Americana Miller), Evening Primrose (Oenothera biennis), Blackcurrant Seed (Ribes nigrum) and/or Macadamia Nut (Macadamia ternifolia). Add a combination of anti-inflammatory and cell regenerative essential oils like Roman Chamomile (Anthemis nobilis), German Chamomile (Matricaria reticulata), Lavender (Lavandula augustifolia), Myrrh (Commiphora myrrha) and/or Everlasting (Helichrysum italicum). Massage ever so gently into the skin and leave the area uncovered.
 
A Stage II bed sore may have an angry purple color, indicating a deep tissue injury. It may either start to show a slight cratering or appear like a surface scrape. Cratering is exactly what you’d think: it’s a sunken area that’s wider at the top of the wound and circles downward, eventually revealing fatty tissue and even bone. Continue to work with your anti-inflammatory and cell regenerative essential oils but consider adding something antibacterial – the most popular being Tea Tree (Melaleuca alternifolia). It has a good track record in hospitals and hospice and has been shown to be effective in treating osteomyelitis and infected chronic wounds (Halcon, et al; American Journal of Infection Control, 2004). I would consider shifting your application to the periphery of the wound because what you don’t want to happen at this stage is for the top to cover over but have the wound continue to grow underneath. Nurses refer to this as an unstageable wound because they’re unable to gauge the depth and extent of the tissue damage and if there’s a thin layer on top but infection underneath, it can have severe consequences. Their protocol from this Stage onward will include keeping the pressure sore well and tightly covered.

With Stage III decubitus ulcers, the wound has a distinct cratering effect that reveals subcutaneous fatty tissues. A wound at this stage is well on its way to being irreparable and my focus shifts to infection and odor control.  The most virulent bug to avoid is Staphylococcus aureus and there are many effective essential oils to consider using. I would forego the fixed oils for the Stage III and IV decubitus ulcers and use pure essential oils either around the perimeter of the wound prior to dressing or include them on the dressing itself.  Since the dressing must be airtight, nurses don’t want anything oily near the edges of the bandaging. Although the phenols and ketones are anti-infectious, you must always be mindful of the elderly or terminal patient’s fragile skin in order to avoid irritation at the application site or cause burning in an open wound. I have found that many of our hospice patients experience a heightened effect to essential oils that I would not ordinarily think twice about using (and not just for wound care). I would, therefore, use monoterpinols like Tea Tree (Melaleuca alternifolia) and/or Geranium (Pelargonium graveolens) with something soothing like Lavender (Lavandula augustifolia) and maybe a touch of something for odor control like Peppermint (Mentha x piperita).

If, however, the patient is otherwise relatively healthy, you may be able to continue to address tissue reparation. As an example, the husband of one of our volunteers had a decubitus ulcer on his back that, due to his diabetes, wasn’t healing and had shown total resistance to traditional pharmaceuticals. His wife described it as being the size of a fifty-cent piece. For three years, he had endured a weekly debridement of the dead tissue and his wife had changed his dressing every night.

I had her apply Tea Tree (Melaleuca alternifolia) around the perimeter of the wound at each dressing change for a week, stop applying it for a week and then resume this routine. After she reported that the tissue appeared to be healing (and that means not becoming covered over but healing from the bottom of the wound upward), I added Everlasting (Helichrysum italicum) and had her repeat the week-on, week-off regimen. About two months later, she reported that the wound was dime-sized, the skin was significantly less inflamed and the depth of the wound was much shallower.  Last week, she reported that the doctor had removed the final dressing from the completely healed wound and her husband was able to go swimming for the first time in years. The thing to keep in mind with this anecdotal study is that the patient was not elderly or terminal and his body still had the capacity to aid in the healing process. Additionally, he was being seen regularly by a physician to be sure the wound was healing properly.

Stage IV decubitus ulcers often “tunnel” all the way to the bone and may have an odor that is unpleasant due to the continual sloughing of dead tissue. The odor is sometimes more debilitating to the patient than the wound itself. He/she is aware of the foul smell and notices when visitors begin to taper off or family begins to comment. It can quickly become a source of stress and severe depression. There are some interesting studies on the positive effects of essential oils in alleviating the odor and of the dramatic effect to a patient’s emotional state. One German study combined clindamycin and chlorophyll (their standard pharmaceuticals for Stage IV pressure sores) with a mixture of Eucalyptus, Tea Tree and Grapefruit essential oils (specific species not identified) and found that the smell associated with necrotic tissue completely dissipated in 2-3 days of treatment (Warnke, P.H., et al; Cancer, 2004). These results would be a tremendous benefit to our hospice patients and I hope to pursue my own study in 2012 on the effects of essential oils on the odor associated with decubitus ulcers and thus the patient’s frame of mind.