What Is Decubitus Ulcer?

Decubitus Ulcer is an injury caused by damage to the skin and tissue under the skin. The severity of a decubitus ulcer may vary, from the redness of the skin to the skin, to open wounds to the skin which may reveal muscle and even bone.

Decubitus arises when the skin receives strong pressure in a short time or light pressure but in a long time. Such an emphasis on the skin will cause a disruption of blood flow so that the area is deprived of oxygen and food. Lack of supply of oxygen and food causes the tissue to become damaged and form ulcer wounds (ulcers). Decubitus often occurs in people with certain conditions that make them difficult to move, especially in people who are too long lying in bed. Other conditions that affect blood flow, such as type 2 diabetes, may also increase the risk of decubitus ulcers.

Areas of the body that commonly experience decubitus ulcers are:

• Waist.
• Back.
• Ankle.
• Buttocks.

Decubitus ulcers are very common in elderly or persons with disabilities. In addition, decubitus ulcers are also common in people who spend a lot of time in wheelchairs or beds, people with brittle skin, or people who can not move without help from others. Decubitus ulcers are generally curable with proper diagnosis and treatment.

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Decubitus ulcer Symptoms
Decubitus often occurs in areas of the body that do not have fatty tissue that is thick and often in contact with the bed or wheelchair. In people who can not get out of bed, decubitus ulcers usually occur in areas:

• Shoulders and shoulders.
• Elbow.
• Behind the head or sides of the head.
• Behind knees, heels, and ankles.
• Around the spine.
• Around the tail bone.

Long wheelchair users can also suffer from decubitus ulcers, which are usually present in areas:

• Buttocks.
• Behind arms and legs.
• Behind the pelvic bone.

Decubitus symptoms generally have almost the same characteristics, although the severity is different. Symptoms commonly found in decubitus ulcer patients are as follows:

• Unusual skin color and texture changes.
• Swollen.
• Appears fluid like pus.
• Changes in skin temperature compared to surrounding normal parts, can be felt colder or warmer.
• Infection appears in the decubitus area.
• Open wounds on the skin.
• The skin becomes softer or harder than the surrounding tissue.

Based on the stage of development of symptoms, decubitus ulcer is divided into several levels (grade) , namely:

• Level 1. Decubitus level 1 is the lightest decubitus. This condition is characterized by discoloration of the skin undergoing ulcers. In white people, ulcers are generally reddish in color, whereas in darker-skinned people it appears purplish or bluish. At this stage, the skin remains intact and does not blister. But it usually feels warm, feels like a sponge, and hard. Areas with ulcers can be itchy or sick.
• Level 2. On decubitus level 2, the skin of the ulcer area is damaged in the epidermis and the dermal skin (dermis). The area of ​​the ulcer will look like an open wound or blister.
• Level 3. At decubitus level 3, the skin on the ulcer area will be damaged thoroughly. This skin damage is followed by damage to the fat tissue beneath it so it looks like a hole in the skin. However, muscle and bone tissue around the ulcer has not been damaged.
• Level 4. Decubitus level 4 is the most severe with the most severe degrees. The skin in the ulcer area is severely damaged, accompanied by necrosis or death in other tissues around the ulcer, such as muscle and bone tissue. People with level 4 decubitus have a risk of infection that can cause death.

In certain cases, a decubitus ulcer may be yellowish or greenish and soft as festering. If the skin tissue damage extends, decubitus ulcers need to be removed. However, ulcers that are covered by a dry layer and show no signs of expansion, need not be removed. The layer is a natural protective mechanism of the body.


Causes of Decubitus ulcer
The main cause of decubitus ulcers is pressure on the body for a long time, thus disrupting the blood flow that carries nutrients and oxygen. Without nutrients and oxygen, skin tissue will be damaged and die. Disruption of blood flow to the skin in the long term, also causes the absence of white blood cells needed to fight infection. When ulcers are formed on the skin, bacteria can infect and damage skin tissue.

In people who are actively moving, pressure on certain body parts will not occur in prolonged manner. The active movement will divide the pressure on the body, so that the flow of blood throughout the body can be kept smooth. Even in the sleep state, the body will not stay constantly, but can move up to 20 times during sleep.

Decubitus may arise due to the following:

• Body pressure by hard surfaces, such as a bed or a wheelchair.
• Pressure on the skin due to unconscious muscle movement. For example muscle spasm.
• Damp skin conditions, can damage the outer skin layer.

The duration of a pressure on the part of the body to form a decubitus ulcer depends on the amount of pressure received and the skin's sensitivity to physical damage. Decubitus levels 3 and 4 can spread rapidly in people at high risk of sores, even ulcers can occur within 1-2 hours. However, in some cases, decubitus skin damage occurs within days of injury or stress.

Some of the factors that can increase a person's risk of having a decubitus ulcer are:

• Disturbance of body movement. Some causes of someone experiencing body movement disorders include:
• Spinal damage that causes the limbs, especially the legs experience paralysis.
• Severe brain injury from a stroke or severe head injury that causes the limb to become paralyzed.
• Diseases that cause progressive central nervous system damage, especially on the part of the nerves that regulate the movement of the body. For example in Alzheimer's disease, multiple sclerosis , and Parkinson's disease.
• Extremely severe pain, making it difficult to move limbs.
• Underwent a healing phase after surgery.
• Be in a coma.
• Having a disease that causes difficult to move the joints of the body, such as rheumatoid art hrititis .
• Less nutritional intake. Nutritional intake that provides nutrients for skin and muscle tissue can be impaired, especially if a person experiences the following conditions:
• Anorexia nervosa , a condition when a person is obsessed with overweight.
• Dehydration due to lack of fluid in the body.
• Dysphagia or difficulty swallowing.
• Certain health conditions. Some of the health conditions of a person who can increase the risk of exposure to sores are:
• Type 1 and 2 diabetes. High blood sugar levels can interfere with blood flow in the skin capillaries, leaving the patient susceptible to decubitus ulcers.
• Peripheral arterial disease ( p eripheral arterial disease ) , where there is disturbance in the foot arteries due to fat deposits, so that the blood flow in the capillaries become abnormal.
• Heart failure. Damage to the heart can cause the organ does not function optimally in pumping blood throughout the body.
• Kidney failure. This condition can cause the buildup of toxic compounds in the blood that can damage skin tissue.
• Chronic lung disease. Various chronic diseases of the lungs can cause the ability of the lungs to decrease, so that the oxygen content in the blood becomes low and encourage the occurrence of ulcers dekubitus.
• Aging skin. Aging skin loses elasticity, making it easier to get injured. The older, the blood flow to the skin will also decrease. In addition, aging skin also contains less fat tissue.
• Incontinence. The condition when a person loses control over the bladder and rectum, which usually occurs in the elderly. This causes the skin around the urethra and the anus becomes moist and susceptible to infection.
• Mental disorders. Mental disorders in a person, such as schizophrenia , can lead to poor nutritional intake and can cause other health problems, such as diabetes or incontinence. Patients with mental disorders also do not have a good awareness of personal hygiene, so more susceptible to infection and injury.
• User of artificial limb (prosthetic). Prosthetic devices, such as prosthetic limbs, can cause persistent pressure on an area of ​​the body.
• Sensory nerve disorders. Sensory nerve disorders cause a person less sensitive in feeling pain, so do not feel any disturbances that trigger dekubitus. Sensory nerve disorders can be caused by spinal cord injury, neurological disorders, and others.
• Smoke.

Diagnosis of Decubitus Ulcer
A decubitus ulcer can be easily diagnosed only from its external appearance. To find out the magnitude of the risks of ulcers increased and increasing, the doctor will perform further tests, including:

• Patient health condition in general.
• The ability of mobility (movement) of the body.
• The existence of problems that interfere with one's posture.
• The presence of symptoms of infection.
• Mental health conditions.
• History has a decubitus ulcer.
• The presence of incontinence (difficult to control urination or defecation).
• Dietary habit.
• Circulatory conditions.

In addition, decubitus sufferers may be advised to undergo blood and urine examination. From the examination of blood can be known condition of health of patients in general. While the urine examination serves to assess the function of the kidney, as well as detect the presence of urinary tract infections in patients.

When a patient is diagnosed with decubitus, the doctor will examine the following to determine the severity.

• Size and depth of ulcer.
• The type of tissue affected by decubitus ulcers, whether it has spread to muscle tissue and bone or still in skin tissue only.
• Decubitus color.
• The extent of the area that undergoes tissue death (necrosis).
• Conditions on the ulcer, such as signs of infection, unpleasant odor, or bleeding.

Observation independently
As a measure to monitor yourself against the risk of a decubitus ulcer, it is advisable to routinely monitor any symptoms that may arise. The most easily observed symptoms are the presence of skin discoloration, as well as the supple feeling that appears in the area.


Treatment of Dekubitus Ulcer
The type of decubitus ulcer treatment given to the patient may vary, depending on the severity of the illness.

The process of decubitus ulcer treatment is not a rapid process. But with good ulcer management, equal body pressure, and nutritional adequacy, decubitus can heal well. Treatments that can be done include the following:

• Changing body position. Performing body movements, although passively, and regular body position change is very important to do in people with dekubitus. Regular body movement can avoid accumulation of pressure on the body, and reduce body pressure in the already decubitus. The doctor will advise on the following:
• Good sleeping and sitting position, including how to get used to doing sleeping and sitting position is good and right.
• How often the patient should do body movement.
• How to keep pressure conditions on your feet everyday.
• How to maintain good posture and correct.
• Special equipment that may be needed.
• Use of mattresses and special pillows. For people with dekubitus, to reduce the pressure on the body part of the ulcer, can be used pillow and mattress antidekubitus ( anti-decubitus pillow and mattress ). These special pillows and mattresses can also be used on people who have to lie down long, as a precaution.
• Selection of special bandages for decubitus healing. Some types of bandages are specially designed to accelerate the recovery and healing of sores in patients. Examples of bandages that can be used are:
• Hydrocolloid bandage. It is a specially designed and gel-containing bandage to accelerate cell regeneration. Gel on the bandage will stimulate cell growth in the dekubitus, while keeping the area around dekubitus remain dry.
• Band of alginate. Made from seaweed that contains calcium and sodium to speed up the healing process of decubitus tissue.
• Creams and ointments. Special creams and ointments for decubitus sufferers can be used to speed up the healing process and prevent further tissue damage.
• Antibiotics. Antibiotics are used to prevent and treat tissue infections due to decubitus ulcers. Antibiotics are also used to prevent the spread of infection if it has occurred.
• Provision of dietary supplements. Some vitamins and dietary supplements can speed the healing process of decubitus, such as vitamin A, vitamin C, protein, and zinc (Zn).
• Removal of damaged tissue (debridement). For healing purposes, patients may undergo treatment to remove dead tissue around the ulcer. Appointment of tissue usually is done under local anesthesia. This method of removing dead tissue can be done by:
• Cleaning by using water pressure. In this method, the doctor will spray high pressure water on the decubitus area to remove the tissue that has been
• Lasers. The dead tissue can be removed using a laser beam.
• Surgery. This is the most common method, where doctors will remove dead tissue using a scalpel.
• Maggot Therapy. Maggot therapy is one of the best methods of removing damaged tissue. Maggots will eat damaged tissue without eating healthy tissue. During the exertion of maggot therapy, the maggots will be affixed to decubitus areas covered with gauze for several days. Once completed, the maggots will be removed from the body.
• Painkillers. Nonsteroi antiinflammatory drugs, such as ibuprofen, can help relieve pain from decubitus in patients. This treatment is useful to allow patients to switch positions on a regular basis and reduce pressure on the body.
• Surgery. Surgery is generally performed to remove tissue in cases of decubitus ulcers level 3 and 4. This is because the damaged tissue at the severity is difficult to heal. Surgery can be done by cutting off the damaged tissue, then directly stitched or done tissue transplant first. Even so, this surgery has a number of risks due to the health conditions of patients who are not good. The risks of surgical removal of tissue in decubitus patients 3 and 4 include:
• Infection; abscess.
• Death from a tissue that is transplanted post-surgery.
• Muscle weakness.
• Blisters on the skin
• The recurrence of decubitus.
• Internal bleeding.
• A blood vein occurs in the legs (deep vein thrombosis).
• Blood poisoning .

Due to the risk of surgery to treat decubitus levels 3 and 4 high enough, patients with poor health conditions are not recommended to undergo surgical procedures. Moreover, if the patient does not have a pillow and mattress specifically for decubitus at home, it is not recommended to undergo surgery due to the risk of recurrence of dekubitus and the risk of complications.


Decubitus ulcer complication
Complications due to decubitus ulcers generally occur in cases of decubitus level 3 or 4, and can endanger the lives of patients. Some of the complications of unsupervised ulcers that are not treated properly are:

• Cellulitis. Cellulitis is a widespread infection from where the occurrence of dekubitus to the inner lining of the skin. Symptoms of cellulitis can be observed from the skin of redness and pain in the ulcer. Without good treatment, infection from cellulitis can spread into blood vessels, muscle tissue, or bone. If a decubitus occurs in the area near the spine and complications arise from cellulitis, the infection may spread to the spine and brain.
• Blood poisoning. In patients with ulcers dekubitus with a weak immune system, can appear infections that spread through the blood circulation. This condition is called blood poisoning or sepsis. In cases of serious sepsis, sepsis due to decubitus can damage various organs resulting in shock (shock ) that can cause death. Sepsis in patients treated with antibiotics and should be monitored closely because sepsis is a medical emergency.
• Bone and joint infections. Infection from the site of the appearance of pressure can also spread to joints ( septic arthritis ) and bone (osteomyelitis). These complications can be treated by use. In severe infections, it is possible to have amputations of bone and joints affected by the infection.
• Necrotizing fasciitis . This type of complication is caused by an infection of a decubitus ulcer by type A streptococcus bacteria, which causes tissue death and rapid spread of infection to the tissues. This condition can be resolved by debridement to remove dead tissue and antibiotics.
• Gas gangrene . This is a condition that arises from the infection of the Clostridium bacteria in the decubitus ulcer area. Clostridium type bacteria can live with little oxygen and produce gas and toxins that are harmful to the patient. To overcome gas gangrene , can be done debridement to remove dead tissue or amputation in more severe cases.
• Cancer. A long-term, untreated decubitus ulcer may turn into squamous cell cancer. A decubitus ulcer that turns into squamous cell cancer is known as Marjolin ulcers. This change is the most severe complication of decubitus ulcers, but rarely occurs.

Decubitus ulcer Prevention
Steps for prevention of daily dehiscitous ulcers are as follows:

• Change your body position regularly. This method is the most effective way of preventing the appearance of a decubitus ulcer. If decubitus has arisen, replacing the body's position regularly can reduce body pressure on the part, as well as provide better healing opportunities in the decubitus. For wheelchair users, it is recommended to change the body position every 15-30 minutes. In patients who are difficult to move from bed, it is advisable to change the body position every 1-2 hours.
• Maintain nutrition and diet. To accelerate the healing process of decubitus ulcers, it is advisable to use a diet rich in protein, vitamins, and minerals. If the patient experiences a loss of appetite due to previous health conditions, the following tips can be done to keep the nutrient intake:
• Eating food in small portions but often, compared to eating with large portions but the frequency is small. The diet can be applied by making a meal schedule.
• Avoid drinking in large quantities before eating.
• If you have difficulty swallowing, can consume food in the form of soup or team.
• Keeping the source of vegetable protein for vegetarian patients.
• Perform a routine skin examination. If a person has a risk of having a decubitus ulcer, it is necessary to check the skin regularly to observe changes. Routine checking is important, especially for people with diabetes and nerve damage that causes the body part is not sensitive to pain.
• Stop smoking .

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