By Tedler D. Depaynos, MD

The female 72 year old patient for the past years, had a series of mild “strokes” which made her limp with much effort but could still ambulate with the aid of her cane. Six months ago, however, she had another “stroke” which finally made her bedridden. Although her children were taking care of her especially financially, their individual work made their presence with her eventually limited. She is being cared for by a relative house help who feeds her, keeps her clean and makes her comfortable in bed.
It was several weeks ago when they noticed that a portion of her sacral skin was becoming reddish and eventually darkening. With time it appeared to be widening. Because the patient was practically paralyzed, she never complained of pain. She also appeared to have difficulty of breathing so that eventually she was brought to the hospital. She was diagnosed to have pneumonia and pressure ulcers.
The pneumonia is one of the expected complications in bedridden patients because of their constant position, non-expansion of their lungs and of course decreased resistance. Atrophy of the muscles, stiffening of joints and even constipation may also occur.
The pressure ulcers or bedsores or “decubitus” ulcers in medical parlance are likewise due to the constant position so that the skin and soft tissues being compressed between the bones of the patient and the bed develop gangrene. “Decubitus” refers to the position taken while lying down. Since it is the buttocks in contact with the bed while lying down, it is usually the location of the ulcers. The blood vessels are compressed by the weight of the patient depriving the tissues of the needed blood supply. This is what happened to this patient. Due to the paralysis and malnutrition of these bed ridden patients, their muscle tone is practically gone.
Obviously, to avoid these complications, good nursing care is a must. I am familiar with a patient who was paralyzed for about 15 years but never developed pressure ulcers. This is due to the constant change of position of the patient which is ideally done every 2 hours by hired nurses all day long. Obviously, most patients cannot afford to provide that service and their children also have to work to support themselves and their families.
Change of position is usually done with soft pillows and sometimes a donut shaped cushion is placed in the sacral area to prevent it from being in direct contact with the bed.
Once a black necrotic skin develops, infection may be inevitable especially so that it is just adjacent to the anus. Prevention of infection is done by cleanliness and eventual debridement or removal of the skin of necrotic tissues. This is usually done under general anesthesia or merely sedation. With wide excision, complete healing of the wound may not be expected but at least infection could be controlled by constant cleansing and dressing and with the use of proper antibiotics. A routine culture and sensitivity test of the bacteria invading the dead tissues is done so that the antibiotics given will surely be effective. If not controlled it may lead to sepsis which may be detrimental to the patient.
Most bedridden patients may not be able to take adequate food also so that the tendency is they become malnourished and their resistance becomes low. This will aggravate the infection. Hence adequate nutrition is also a must. For patients who could not swallow, a nasogastric tube is inserted where feeding is done. IV fluids with high calories may also be inserted to help in the patient’s nutrition as well as hydration.
In most hospital settings, patients expected to have very limited physical movements are sometimes referred to Physical Rehab MDs and personnel mainly to prevent the complications.
Heat or ultrasound may be applied to relieve the pain, to relax the muscles and to dilate the blood vessels in areas that needed it. Massage with stretching and contraction of the muscles to prevent atrophy and strengthen them may also be done. To prevent joint stiffness, flexing no matter how painful maybe basic. Of course, the Rehab Specialists would determine what is best for the patient.
They may even teach good nursing care to the relatives and whoever would be taking care of the patient so the unwanted complications could be prevented. Finally, psychological strengthening and encouragement is never forgotten!
Arrangements may also be done for the Rehab Experts to do home visitations if needed.**