What should you pay attention to when caring for bedridden patients?

Author: Pan Pengwei, The First Affiliated Hospital of Zhengzhou University

Reviewer: Zhang Qi, deputy chief physician, First Affiliated Hospital of Zhengzhou University

In today's society, the incidence of cerebrovascular diseases is high, and the age of onset tends to be younger. With the intervention of medical means, many patients can achieve complete recovery, but many patients are left with serious sequelae, or the disease recovers slowly, and activities to maintain basic physiological needs (eating, excretion, etc.) must be carried out in bed. When caring for such patients, due to their weakened physical activity, decreased immune function and reduced self-care ability, complications such as pressure sores, deep vein thrombosis of the lower limbs, lung infection and urinary tract infection are very likely to occur. Once the above complications occur, it will not only be detrimental to the patient's recovery, but also aggravate the patient's condition. Sometimes serious complications may also cause irreversible consequences. Taking reasonable and effective nursing methods can prevent and reduce the occurrence of complications. The following introduces several common complications that may occur in bedridden patients and related nursing methods.

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1. Pressure ulcers

Pressure sores, also known as pressure injuries, are localized injuries to the skin and/or underlying tissue, usually over bony prominences, or where medical devices or other equipment are in contact. The skin of a pressure sore can be intact or ulcerated, and can be painful.

1. Risk factors for pressure ulcers

The main risk factors for pressure sores are: ① Exogenous factors: such as vertical pressure and shear force. ② Endogenous factors: such as limited movement and behavior (such as recent lower limb fractures, spinal cord injuries), sensory impairment, advanced age, malnutrition, moist skin (such as incontinence of stool and urine), etc. ③ Iatrogenic factors: such as the use of medical devices such as plaster, ventilator masks and other fixed brackets.

2. Prevention and care of pressure sores

(1) Keep the skin clean and dry. It is recommended to use skin protection products on skin areas that are prone to immersion or excessive dryness. Be careful not to scrub the skin over bony prominences.

(2) Proper positioning. A soft pillow or other decompression tool can be used to pad the entire length of the calf to ensure that the heel does not come into direct contact with the bed surface. Unless necessary for the condition or treatment, avoid the patient lying in a position where the head of the bed is raised more than 30° for a long time; when lying on the side, keep the back at an angle of 30° to 40° to the horizontal bed surface. When positioning the patient, avoid direct contact between the skin and medical devices.

(3) Change body position in time. When the patient's condition allows, the body position should be changed at least every 2 hours when using an ordinary mattress; when using a high-specification foam mattress, the body position can be changed every 3 to 4 hours. Avoid dragging, pulling, pushing, and pulling during the operation.

(4) Use decompression tools. It is recommended to use a high-specification foam mattress, or an alternating air mattress or other decompression mattress. Local decompression tools such as soft pillows and preventive dressings can be used locally.

2. Deep vein thrombosis of lower extremities

Deep vein thrombosis refers to abnormal coagulation of blood in the lumen of deep veins, which causes complete or incomplete blockage of blood vessels. It is more common in the lower limbs. Deep vein thrombosis of the lower limbs generally has no obvious clinical symptoms and is easily ignored. For patients with symptoms, the main manifestations are swelling and pain in the lower limbs. Some patients also experience increased skin temperature and skin color changes in the limbs. At the same time, they may be accompanied by systemic reactions such as increased body temperature and increased pulse rate.

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1. Risk factors for deep vein thrombosis in the lower extremities

(1) Factors related to venous injury: trauma, surgery, chemical injury, infectious injury, etc.

(2) Factors related to blood stasis: long-term bed rest, paralysis, immobilization, previous history of thrombosis, etc.

(3) Factors related to hypercoagulable state of blood: advanced age, obesity, malignant tumors, polycythemia, artificial blood vessels or endovascular grafts, pregnancy, postpartum period, long-term oral contraceptive use, etc.

2. Prevention and care of deep vein thrombosis in lower extremities

(1) Education on prevention knowledge: If the condition permits, encourage patients to drink plenty of water to avoid blood concentration; advise patients to improve their lifestyle, such as quitting smoking, quitting drinking, and controlling blood sugar and blood lipids.

(2) Correctly guide and assist patients in bed activities, such as ankle pump exercises and quadriceps functional exercises.

(3) Avoid placing a hard pillow under the knee and excessive hip flexion. If the condition permits, elevate the affected limb to promote venous return.

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(4) Regularly assess the patient’s lower limbs. If any swelling, pain, changes in skin temperature and color, or abnormal sensation are detected, notify the doctor and take appropriate measures.

(5) Use gradient compression stockings. Before use, measure the size of the patient's lower limbs according to the product instructions and select the appropriate type of gradient compression stockings. During use, regularly check whether the gradient compression stockings are worn correctly and the condition of the lower limb skin. If the patient tolerates it, it is recommended to wear it day and night and take it off intermittently.

(6) Use an intermittent pneumatic compression device or an intravenous foot pump.

3. Lung infection

Pulmonary infectious diseases include pneumonia and lung abscess, among which pneumonia is the most common. Pneumonia refers to inflammation of the terminal airways, alveoli and lung interstitium, which can be caused by pathogenic microorganisms, physical and chemical stimulation and immune damage. Common clinical manifestations include fever, cough, sputum, or aggravation of existing respiratory symptoms, and the appearance of purulent or bloody sputum, with or without chest pain.

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1. Risk factors for lung infection

Bed rest is an important factor in the occurrence of lung infection. Other factors include the following categories.

(1) Patient factors: such as age ≥ 65 years; smoking; long-term alcoholism or malnutrition; chronic lung disease or other diseases such as malignant tumors, immunodeficiency, diabetes, heart failure, chronic renal insufficiency, chronic liver disease, neuromuscular disease, etc.

(2) Factors related to aspiration: such as swallowing dysfunction, gastroesophageal reflux, delayed gastric emptying, impaired consciousness, abnormal mental state, periodontal disease or poor oral hygiene, etc.

(3) Environmental factors: such as poor ventilation, air pollution, seasonal and climate changes, etc.

2. Prevention and care of lung infection

(1) Take basic preventive measures, including maintaining appropriate environmental temperature and humidity, suctioning sputum as needed, and keeping the patient's oral cavity clean.

(2) Raise the head of the bed. If the patient's condition permits and during nasogastric feeding, the head of the bed should be raised 30° to 45° and maintained for 30 minutes after nasogastric feeding.

(3) Early ambulation: Under the premise of ensuring the safety of patients, we encourage and assist patients to get out of bed and move around early.

(4) Perform respiratory function exercises and promote effective expectoration. Instruct patients to practice using abdominal breathing and other respiratory function exercises and effective coughing methods. For patients who have been bedridden for a long time and have difficulty expectorating, turn them over regularly and use measures such as nebulization inhalation, chest percussion, postural drainage, vibration expectoration, and suction to promote expectoration.

4. Urinary tract infection

Urinary system infection is also called urinary tract infection. Common clinical manifestations include frequent urination, urgent urination, painful urination, waist and abdominal pain, etc., which may be accompanied by systemic symptoms such as fever. Some patients (such as the elderly and pregnant women) may have no symptoms of infection, and only abnormal urine test results.

1. Risk factors for urinary tract infection

Bed rest is an important factor in the occurrence of urinary tract infection. Other factors include the following categories.

(1) Patient factors: age ≥ 65 years; postmenopausal or pregnant women; incontinence of stool or urine; oliguria; malnutrition; impaired consciousness, etc.

(2) Disease-related factors: combined with urinary system diseases (such as chronic kidney disease, urinary tract stones, prostatic hyperplasia, vesicoureteral reflux, etc.) or other diseases (such as diabetes, advanced tumors, hyperuricemia, etc.).

(3) Iatrogenic factors: such as catheterization, indwelling urinary catheter, cystostomy, etc.

2. Prevention and care of urinary tract infection

(1) Observation of the condition: Assess the patient's body temperature, waist and abdominal pain, urination status (frequent urination, urgency, and pain during urination), and urine properties (color, properties, urine volume, etc.) every day.

(2) Perineal care: For patients without indwelling catheters, use 41-43°C warm water to clean the perineum and the inner upper 1/3 of the thigh every day; for patients with indwelling catheters, use warm water, saline or sterile water for injection to clean the perineum, urethral opening, and the surface of the catheter every day. Perform perineal care 1-2 times a day, and the frequency can be increased according to the patient's condition and treatment needs (such as incontinence).

(3) For patients with indwelling urinary catheters, in addition to taking the above precautions, they should also take good care of the catheter. The following suggestions are made. ① Properly fix the urinary catheter and urine collection bag, keep the urine collection bag below the bladder level and avoid touching the ground, and clamp the drainage tube when moving or transporting the patient to prevent urine backflow. ② Keep the urine collection device closed, unobstructed and intact, and try to avoid disconnecting the urinary catheter and urine collection bag. ③ Empty the urine collection bag in time (at least once every 8 hours or when the urine collection bag is 2/3 full or before transporting the patient), avoid the urine collection bag's urination port touching the collection container, and close the urination port in time. ④ Replace the urinary catheter: The replacement time of the urinary catheter should not be longer than the time limit required by the product manual. If the urinary catheter is damaged, scaled, drainage is not smooth, or accidentally falls out, the urinary catheter and urine collection bag should be replaced in time. ⑤ Replace the urine collection bag: The replacement time should not be longer than the time limit required by the product manual. If infection, blockage, etc. occur, it should be replaced in time.

(4) Early mobility: If the condition permits, patients should be encouraged to get out of bed and move around as soon as possible (if a urinary catheter is in place, the catheter and urine collection bag should be properly fixed). If necessary, they should be provided with appropriate auxiliary tools to ensure their safety. For those who cannot get out of bed, they should be assisted to change their body position regularly.

(5) Dietary guidance: Develop an individualized diet plan based on the patient's condition. It is recommended to eat a light diet, avoid spicy and irritating foods, and ensure a balance of calories, protein, vitamins, water, and minerals. If the patient's condition permits, adults should drink 2000-3000 ml of water per day, try to urinate every 2-3 hours, and maintain a urine volume of more than 1500 ml per day. Limit the amount of water you drink before going to bed to reduce urine volume at night.

At present, a considerable number of patients are bedridden for a long time due to illness, and they cannot meet the conditions for hospitalization and need to stay in bed at home. When taking care of such patients, family members or other caregivers need to be serious and responsible. I hope that through this article, they can learn more about the precautions for taking care of bedridden patients, which will help bedridden patients recover as soon as possible.