Bedsores are damage to the skin and subcutaneous tissue that result from the compression of the tissues with a hard surface (bed, chair, orthopedic appliances).
Most often they are formed in people who are obese or, conversely, depleted. Diabetes mellitus, severe heart failure, strokes, craniocerebral trauma are also typical risk factors.
It is known that the nutrition of the tissues of our body is carried out by blood, which comes through vessels and capillaries. Skin compression leads to poor nutrition. Each of us can easily carry out a simple experiment: take a transparent glass and tightly squeeze it with your fingers.Through the glass you will see that the tips of your fingers are white – this is due to their bleeding, because it is the blood that gives the skin a physiological pink color. If the squeezing continues for a long time, necrosis (necrosis) of the tissues can occur. The terms for the formation of bedsores are individual and largely depend on the general state of the organism. It is not uncommon for a bed patient, whose skin has been healthy for many months and even years, was covered with multiple bedsores in 1-2 days. Usually this is due to the attachment of some disease or the deterioration of the current already available.
In January 2015, a 46-year-old patient suffering from myasthenia gravis was brought to the intensive care unit, a serious illness characterized by gradually growing muscle weakness. For several years she practically did not get out of bed, but thanks to good skin care she had no bedsores. As a result of the progression of the disease, a weakness of the respiratory muscles appeared, which led to shortness of breath, which was the reason for hospitalization. Literally on the first day of her stay in the intensive care unit, despite proper skin care, she had deep sores on the rump with the size of two palms. Apparently, the cause of them was hypoxia – an insufficient saturation of the blood with oxygen, which, combined with inactivity, led to a disturbance in the nutrition of the skin and subcutaneous tissue. Against the background of complex treatment, the patient’s condition improved, while the bedsores were gradually cured. Stay in the intensive care unit lasted more than six months, but as a result, the patient was discharged home, now she uses a home apparatus for ventilation.
Excessive squeezing of the skin is the main, but not the only cause of pressure sores. Some contribution can make so-called shear forces . In order to understand what it is, do the following experiment. Place a bare arm on the table so that the forearm lies on the table, and the elbow hangs a few centimeters. Firmly pressing your forearm against the surface of the table, pull your hand toward you. The skin, adhering to the table, remains immobile, and the elbow will move slightly. This is possible due to the elasticity of the skin and subcutaneous tissues. Stretching the tissues between the bone and the skin causes a worsening of the blood supply, as a result of which bedsores can form in deep tissues with intact skin.
When a sedentary patient tries to move, there may be a situation where the skin remains pressed against the bed, and the bones move slightly.This leads to compression or even rupture of blood vessels, which disrupts the nutrition of deep tissues, causing the appearance of subcutaneous decubitus. The same happens when the patients slide from the bed, pulling the sheets out from under them, and in other similar situations.
By the way, abrasions, provoked by stretching from under the sick bed sheet or bed-board, are easily infected, which ultimately accelerates the development of pressure sores.
All bedridden patients should be examined daily, revealing bedsores at the earliest stages. First of all, assess the condition of the skin above the bony protuberances – in the nape of the neck, scapulas, sacrum, heels. If the patient lies on his side, bedsores can form in the region of pelvic bones, trochanter of the femur, on the knees.
The first stage of development of pressure ulcers is the reddening of the area of the skin, which does not go away when you press a finger on it.Then there are bubbles, reminiscent of those that occur with burns of the second degree. After this, if you do not take the necessary measures, an ulcer opens, which deepens to the bone, gradually destroying them. It is clear that the further the process went, the less chance of recovery, so prevention is very important. Let us dwell on it in detail.
• The main and most simple preventive measure is the use of an anti- decubitus mattress. Details about him are written in the chapter devoted to motor rehabilitation. Its cost is 3-4 thousand rubles (September 2016). By paying this amount, you can avoid large spending on treatment, and most importantly – significantly relieve the patient’s life. To some extent, the mattress can be replaced with rubber underlays under the sacrum and heels, however these devices are much less reliable and quite inconvenient.
• Change the patient’s position as often as possible. The methods of turning in bed are described in detail in the chapter on motor rehabilitation.Ideally, the turn needs to be done every two hours.
• Try to keep the skin clean. Daily 1-2 times treat it with camphor alcohol. It should not be too wet or dry.
• Make sure that there are no wrinkles, crumbs from food and other foreign objects on the sheet.
• Do not pull the sheets and the vessel out of the patients, but take them slowly and carefully.
• Do not allow patients to slip from the bed and a prolonged forced position in bed.
• Do not place heating devices (reflectors, oil heaters) near the patient’s bed. He can get burned because of the inability to change the position of the body.
• Do not use oilcloth to place under the patient’s body. If the patient does not control urination, it is better to put diapers on him, and a moisture -absorbing disposable sheet ( under the body) should be placed under the body . Adhesives cause excessive moisturizing of the skin, which in the future can worsen its protective properties and lead to the development of pressure sores.
• Use special skin care products instead of soap. They do not cause skin irritation, since they have a neutral, not an alkaline reaction.
At the first stage of development of decubitus, when there is no skin defect, it is enough just to ease pressure on the skin, for which the above-mentioned anti- bedsore mattresses and rubber circles are used. Turning in bed once every two hours is already mandatory, not desirable.Slapping the palm over reddened places can also speed recovery.
When a skin defect occurs, a solution of hydrogen peroxide is used – it allows you to clean the wound thoroughly, removing dirt and infected contents from it. Then, the same ointments that are usually prescribed for the treatment of open wounds are selected. Argosulfan is well proven – it contains an antibiotic and silver ions. Ointment allows you to quickly cope with the infection, has an analgesic effect and, as a rule, is well tolerated. Argosulfan is applied abundantly on the wound 2-3 times a day, the course of treatment depends on the speed of healing and can be up to two months. Levomekol and levosin are also shown . These ointments contain an antibiotic and a wound healing component, and levosin is also a local anesthetic trimomein , so the use of this ointment is preferred in cases of severe pain syndrome. The complex effect is sprayed with olazole , which contains sea buckthorn oil, an antibiotic, a topical anesthetic, and boric acid.
Solcoseryl or actovegin may be added to the treatment in the form of ointments, however, their intravenous administration is more effective, which strengthens the defenses of the body and prevents the emergence of new pressure sores.
Severe deep bedsores are an occasion to seek help from a surgeon. The operation consists in removing necrotic tissues, after which ointments are applied, which have already been discussed in this section.
On sale there are plastic bottles, when pressed on which a jet of hydrogen peroxide ishes all pathological contents from the decubitus. If you bought hydrogen peroxide in a glass container, you can pour it into a 20-ml syringe, attaching a needle to it from an insulin syringe. The needle should be fixed as best as possible, with adhesive tape or tape. When you press the piston, the jet will be thin, but very powerful, with its help you can separate the purulent masses from healthy tissues. After drying, apply ointment.
Yes. Instead of an ointment, the use of such drugs is acceptable. Usually, the bottom of the bed is smeared with potassium permanganate, and the green spot is around it. Treatment should be carried out often, 3-6 times a day. At night, when the patient is sleeping, you can apply a bandage with a spray of olazole or panthenol (apply a very thick layer, to a centimeter thick) and cover with a wide gauze bandage, strengthening its edges with adhesive tape . In the morning remove the bandage, rinse the wound with hydrogen peroxide and continue drying.
Correct speech can be restored only by a speech therapist. The task of relatives – as soon as possible to turn to such a specialist and not try to do something yourself. Inept attempts to teach the patient to speak bring more harm than good. For example, if you ask the patient to repeat the name of an item for you, you may be able to do it. True, the consequences will become unexpected for you: a so-called echolalia can form – a person will continue to repeat certain words, but he himself can still say nothing.
If a patient is able to pronounce a word and you encourage him to often reproduce this success, a verbal embolus may arise – the patient without any sense and reason will repeat the word, but to teach him to speak other words will be much more difficult. If the patient can repeat after you the name of an object, do not rush to rejoice. Often it happens that he will use these words in his original form, without declension. Such a speech disorder is called agrammatism .
Only an experienced speech therapist will be able to draw up the correct program for restoring speech and combating the violation of her perception.
As a rule, the exercises selected by the speech therapist at the beginning of the recovery cycle are of a non-verbal nature. This is the folding ofpuzzles , drawing, the construction of figures using cubes. You can offer games in cards, dominoes, lotto. In the next stages, patients are given jobs to combine the picture and the signature to it. The restoration of writing skills is carried out by recording dictation of words and numbers.
It should be remembered that classes with a speech therapist should be conducted in silence. Extraneous noises, a working TV or radio interfere with a patient with impaired speech much more than a healthy person. Moreover, it is impossible to talk to two people at the same time with something to the patient – such a flow of information is difficult for him to understand.
There are several more rules for communicating with a patient with a speech disorder.
• Talk more in his presence. He must participate in general conversations, it speeds up recovery and improves the emotional background.
• Classes with a speech therapist should be conducted as early as possible after the discovery of a speech defect. The first three weeks from the moment of the disease are most productive. Then the compensatory capacities of the body gradually decrease. It is conditionally considered that after two years from the beginning of the disease recovery is impossible.
• Try to refer to the patient with short and clear phrases.
• When talking with a patient, speak slowly, pronouncing words well.
• Do not raise your voice when talking to a patient and do not lisp. Aphasia (a violation of understanding and formulating speech) – this is not deafness and not dementia!
• Ask at first such questions, to which you can answer “yes” or “no”.
• Try not to interrupt the patient – the way will express his thought to the end, even if it does not turn out as quickly as we would like.
Edema of the extremities is a natural complication of stroke. More often it occurs in people who do not use the affected limb – do not try to move it, do not perform restorative exercises. The cause of edema is the excessive tone of the flexor muscles, as a result of which the outflow on the veins clamped by these muscles suffers. Ways to combat swelling are as follows:
• Try to do exercises more often. The contractions of the muscles of the sick arm, alternating with relaxations, contribute to the improvement of venous outflow from the diseased limb, hence, reduce puffiness.
• If the hand does not move at all, try to at least passively change its position. Lie with arms outstretched (or put a pillow between your arm and body) is most effective for eliminating edema.
• During waking and walking, you can put a small cushion between the arm and the body so that the hand is not pressed.
• There is a therapeutic massage that helps to reduce swelling of paralyzed limbs.
• Medical treatment of edema is usually ineffective. Nevertheless, in conjunction with the above measures, taking medication can sometimes be helpful. As a rule, in such cases, prescribe detraleks and / or homeopathic drug lymphomyositis .
• If the hand swells very strongly, cyanotic staining of the affected limb appears, you can think of venous thrombosis. In this situation, ultrasound of the veins of the arm and consultation of the vascular surgeon are necessary.
You can use the recommendations above. In addition, you can use elastic bandages or, much more effectively, compression underwear – knee-highs, stockings, tights. To improve venous outflow it is useful to dilute legs to the sides during sleep and rest. For this purpose, a pillow can be placed between the knees.
Usually, laxatives are prescribed to solve this problem, for example dufalak . There are microclycers microlux , their application is very effective. If medications do not help, the enema should be staged. Normally, the chair should be 1 time per day, a delay for a longer period is always bad.
Do not forget about the increase in the amount of fiber in the patient’s diet – give him prunes, food bran, drug ryacen RD. This can increase intestinal motility and help achieve a regular stool.
In such cases, special nutritional mixtures are usually prescribed – Nutridrink / Nutrikomp or baby food (preferably meat, it has more nutrients).You can diversify the diet with jelly, yogurt.
For more than three years I have been watching a patient who is 92 years old at the moment. After a stroke, she practically does not move around the apartment and can not swallow solid food. About 90% of its diet is a nutrient mix ” Nutridrink “, sometimes it adds a little baby food or jelly. Despite the monotonous and relatively meager diet, the patient is alive and feels good, as far as possible in her condition. All the needs of the body in nutrients are covered by Nutridrink .
After feeding, you must sit for half an hour, if it is not possible, then at least raise the head end of the bed.
In such cases it is necessary to offer semi-liquid products – jelly, kefir, yoghurt. Sometimes you can try to give 1-2 sips of water, and then seize it with something hard, it will improve the swallowing of the liquid.
There is an exercise that sometimes helps to stimulate the restoration of a swallowing reflex. After each sip of something liquid, a soft, damp toothbrush without paste is needed to pat the lower wisdom teeth (or the gums in their place, if they are removed) on both sides. It is enough to perform several massage movements, but it should be done often.
Measures to eliminate muscle spasm are as follows:
• Change the patient’s position regularly;
• as often as possible, perform slow, passive movements in the joints of the affected hand with the help of an assistant or with a healthy hand;
• The hand should not be on weight – during rest, always place it on the pedestal, the position of the limb should be the middle between the extreme flexion and extension;
• prescribed by a doctor may use drugs or sirdalud Mydocalmum. They help to cope with spasm, but experience shows that their reception leads to muscle weakness, which makes rehabilitation difficult and worsens the quality of life.
This question is so important that I consider it necessary to dwell on it in more detail. Unfortunately, the prophylactic appointment of droppers to patients who have suffered a stroke is very common. In the offices of the day hospital, polyclinics are administered solutions containing euphyllin, piracetam , cavinton and other similar preparations. Patients stand in line, and droppers are prescribed from a certain date, which are prepared in advance, often for 2-3 months …
However, the effectiveness of such methods of therapy is low. The fact that the treatment with droppers should be prescribed only in case of worsening of the course of diseases! In particular, with a repeated stroke, exacerbation of cerebral circulatory insufficiency with clear symptoms (for example, increased dizziness) or in other similar situations. The prophylactic effect of a repeated stroke does not have a dropper. It is not uncommon for patients to have a stroke immediately after the completion of the dropper course. Not from droppers, of course, but as a result of the progression of a chronic disease. No droppers can prevent this.
Remember: the treatment of any disease has only two goals – improving the prognosis and improving the quality of life. No others. If a drug does not improve the prognosis and well-being, it is not needed. To the fullest extent, this refers to “preventive” droppers with caviton or pyracetam .
Yes, of course, for the prevention of stroke are used pills, which have already been discussed in this book. I think it will be useful to repeat their groups and names.
First, it is necessary to prevent the progression of atherosclerosis. For this purpose there statins ( Crestor , Lipitor and others), ezetrol as a possible addition to these, as well as fibrates ( traykor , lipantil ) as an alternative to statins in some cases. Drugs are prescribed for life, require blood test control – lipidograms , transaminases ALT and AST, creatine phosphokinase .
Secondly, we must achieve a reduction in blood clotting – for this purpose, aspirin is used. The dose of 100 mg or more per day has a proven effect. Usually appoint thrombotic ACC 100 mg 1 time per day immediately before meals or cardiomagnesium 150 mg once a day, regardless of food. Stronger drugs are prescribed at the discretion of the attending physician, they require monitoring of blood coagulability and close observation.
Thirdly, it is necessary to lower blood pressure if the patient suffers from hypertension. Preparations are described in detail in the chapter devoted to this disease.
Fourthly, in the presence of atrial fibrillation or heart aneurysm, drugs from the group of anticoagulants must be taken. Usually it is warfarin , pradaxa , xarelto . Read more about this in the chapter, which deals with the treatment of the permanent form of atrial fibrillation.
No other drug groups can prevent stroke. They have either a symptomatic effect – ease the course of the disease, eliminating symptoms, or simply useless.
No. Possible benefits for a person who did not suffer from a heart attack and stroke are less than the harm that regular aspirin can cause. The most undesirable consequence of this is the formation of a stomach ulcer with a risk of bleeding. In patients who have suffered a stroke, this risk has to be tolerated – the benefits of aspirin are very high for them.
If the patient has become dangerous to others or for himself, it is impossible to do without the help of a psychiatrist. The psychiatrist is called to the house through the ambulance service 03. Hospitalization is possible , where patients will be prescribed medications that have a calming effect, usually sonapaks or any drugs of a group of neuroleptics.
The night from 1 to 2 February 2001 I remembered well not only because she was my last night as an ambulance doctor, but also because she could be the last in my life. I received a call to a patient whose relatives reported that the patient who had suffered a stroke “became ill.” Walking up to the fifth floor, I saw a 55-year-old strong man who was standing in the stairwell at the door of his apartment, hiding his hands behind his back, to which I did not pay attention at first. Instead of greeting, he uttered words that terrified me. He asked: “And who is this behind you and smiles so creepy?” I did not suspect any treachery, so I was frightened by this phrase, and slowly began to turn around. Behind my back, of course, there was no one, but with a sidelong glance I caught that the patient made a quick move in my direction.I dashed in the opposite direction and managed – his hand, with the sharpening in it, passed by. The relatives who had come to the rescue grabbed the patient from behind, and we were able to immobilize him and take away his weapons. The specialized psychiatric brigade that I summoned to help brought him to a psychiatric hospital. While we waited for the brigade, my relatives told me that after a stroke a few months ago in the frontal lobe of the brain, the patient completely recovered his motor functions, but the psyche changed seriously. From a relatively quiet (though abused alcohol) person, he turned into an aggressive psychopath – more than once threatened to kill his wife and children, once chased with an ax over a small grandson, frightening him to stutter. When I asked why they did not go to a psychiatrist, the answer was:”And we did not know how to get him out of the house to the psychoneurological dispensary, he did not want to go there.” The fact that an aggressive person should be called a psychiatrist at home, they for some reason did not think.
In such situations, too, need the help of a psychiatrist. There are psychotropic drugs, such as exelon , reminil , which in some cases help to cope with dementia (this is the name of the condition in question).
The 88-year-old patient, whom I observe about the constant form of atrial fibrillation, suffered a stroke, after which he ceased to recognize relatives, often “talked”, talked with non-existent interlocutors, for example, with a long-dead brother. Relatives have already lost hope for an improvement in his condition, but after consulting a psychiatrist and starting a remineral, it has improved significantly. He himself leaves the house, does shopping in the store, reads books and newspapers, watches TV, and can tell in detail what was going on.
Self-medication in this situation is unacceptable, since the drugs have serious side effects, psychiatrist consultation is mandatory.
There is a rule: you have to train before the pain and a little more. Therefore, to continue training is necessary, albeit less than before. You can spend a few short workouts instead of one long. You do not need to break precisely.
Because most of the load falls on it. When restoring the function of a paralyzed leg, this will pass.
In addition to those exercises, which have already been discussed in this book, there is a relatively simple restorative technique. It consists in the following. The patient is given baby cubes, which he must take with a sick hand and shift to another place. When this exercise starts to work out, they switch to smaller objects, for example, pencils, counting sticks, paper clips. At the final stage, 1 kg of buckwheat and 1 kg of rice are mixed, and the patient spreads these cereals in different containers. Usually the successful completion of the final stage brings great moral satisfaction.
In the literature on the problem of stroke, there are recommendations for providing first aid to the sick. I must say that our capabilities are not great. So, it is necessary:
• put the patient on the bed;
• Ensure the flow of fresh air by opening the window;
• Turn your head to one side when you start vomiting, so that the patient does not choke.
In general, a set of simple and obvious actions.
In my opinion, the main problem is to distinguish a patient with suspected stroke from a person suffering from another disease that has similar symptoms.
If the patient is conscious, then everything is simple. We perform the above actions, call an ambulance on the mobile 911 and calmly wait. If a person is conscious, then in the short run he is not in danger.
It is quite another matter if the patient is unconscious. Delay can cost him his life, even a timely call of an ambulance will not always allow him to save, although, of course, this is the best thing you can do. The dispatcher must be informed that the patient is unconscious, the brigade is sent to such patients first of all. If the dispatcher will ask additional questions, try to answer them clearly and without unnecessary details. Well, for now the team is on the road, you can try to help yourself.