Bedsores (Pressure Sores)

Bedsores, also called decubitus ulcer or pressure sores or pressure ulcers are areas of damage caused to the skin and underlying tissues as a result of being in a single position for a prolonged period.

These often develop at areas where the skin is in close proximity to the bones such as your heels, ankles, back, hips, elbows, and tailbone.

People with a medical condition that interferes with their ability to change positions requires the use of a wheelchair or keeps them bedridden for a long time are at a higher risk of developing bedsores.

These ulcers develop quickly and are often difficult to treat in advanced stages. Change of position every two hours and maintaining your skin dry can help prevent some bedsores and help with healing.

Bedsores are divided into four stages based on symptoms severity. This staging helps in diagnosing the ulcers.

The National Pressure Ulcer Advisory Panel, a professional organization that promotes the prevention and treatment of pressure ulcers, defines each stage as follows:

Stage I: The beginning stage of a pressure sore has the following characteristics:

There is no breach in the skin, but it may be discolored. The skin may appear red in people with lighter skin complexion, and the skin does not briefly lighten (blanch) when touched.

In people with a darker complexion, the skin may show bluish to purple discoloration, and it doesn't blanch when touched.

The area may be tender, painful, firm, soft, warm or cool compared with the surrounding skin.

Stage II: The outer layer of skin (epidermis) and a portion of the underlying layer of skin (dermis) are damaged or lost.

This is an open wound with signs of tissue death surrounding the wound. The ulcer may be shallow with a pinkish or red colored base.

The wound may also appear as a fluid-filled blister or a ruptured blister.

Stage III: At this stage, ulcer becomes a deep wound with the loss of skin exposing some fat.

The ulcer appears like a crater. The base of the wound may contain dead tissue that looks yellowish.

The damage may be very extensive, and may involve several layers of healthy skin.

Stage IV: A stage IV ulcer involves a large amount of tissue loss. The wound may extend very deep enough to expose your muscle, bone or tendons.

The base of the wound often contains dead tissue that is yellowish, dark and crusty.
Unstageable: A pressure ulcer is categorized as unstageable if its top layer is covered with yellow, brown, black or dead tissue.

In such ulcers, it is not possible to perceive the depth of the wound.

Deep tissue injury: A deep tissue injury may have the following signs:

Discolored skin – purple or maroon, without a breach in the skin. A blood-filled blister may be present.

The area becomes firm, painful, and may feel warm or cool compared to the surrounding skin.

In people with a darker complexion, a shiny patch or changes in skin tone may develop.

Common sites of pressure sore. In people who use a wheelchair from a prolonged time, pressure sores often occur on the skin of the following area:

• Tailbone or buttocks
• Shoulder blades and spine
• Back portion of arms and legs where they rest against the chair
• In people who are confined to a bed for long-term, common sites include the following:
• Back or sides of the head
• Rim of the ears
• Shoulders or shoulder blades
• Hip, lower back or tailbone
• Heels, ankles and skin behind the knees

When you find early signs or symptoms of a pressure ulcer, change your position to relieve the pressure on that area.

If you do not see improvement within 24 to 48 hours, contact your doctor. Seek immediate medical attention if you see signs of infection such as fever, foul smelling drainage from a sore, increased heat and redness in the surrounding skin.

Bedsores are mainly caused due to pressure against the skin that constrains the flow of blood to the skin and underlying tissues.

Other factors related to restricted movements make the skin vulnerable to damage and contribute to the development of pressure sores.

Three primary contributing factors are:

Sustained pressure: When you lie down on a certain part of your body for prolonged periods, your skin may get damaged.

This occurs because your skin and the underlying tissues become entrapped between the bone and a hard surface such as a wheelchair or a bed, the resultant pressure will be higher than the pressure of the blood flowing in the tiny vessels (capillaries) that supply oxygen and other nutrients to the tissues.

Due to the lack of these essential nutrients, the skin cells and tissues get damaged and eventually die.

This type of pressure tends to happen in areas where your skin is thinner or is not well-padded with muscle or fat, for example, the skin that lies over a bone or cartilage, such as your spine, tailbone, shoulder blades, hips, heels, and elbows.

Friction: Friction is the resistance to motion.

Pressure ulcers may occur when your skin gets rubbed against a rough surface, for an instance, when you change your position or when a care provider moves you. The friction may even be more if the skin is moist.

Friction damages the outermost layer of skin making it fragile and more vulnerable to injury.

Shear: Shear results from two surfaces moving in the opposite directions. For instance, when a hospital bed is elevated at the head portion, you may slide down in bed.

As the tailbone moves down, the skin overlying the bone stays in place - essentially pulling it towards the opposite direction.

This may cause injury to tissues and blood vessels, and make the area more vulnerable to damage from sustained pressure.

To diagnose and evaluate a bedsore, your doctor will determine the size and depth of the ulcer, and check for the following signs:

• Presence of bleeding, fluids or debris in the wound that can indicate severe infection
• Foul odor that indicates an infection or dead tissue
• Spreading tissue damage or infection in the area surrounding the wound
• Other pressure sores over your body

Questions your doctor may ask:

• When did the pressure sore first appear?
• What is the intensity of your pain?
• Have you had pressure sores in the past?
• How were they managed, and what was the outcome of your treatment?
• What kind of care assistance is available to you?
• What routine do you follow while changing positions?
• What other medical conditions have you been diagnosed with, and what is your current treatment?
• What is your normal daily diet?
• How much amount of water and other fluids do you drink each day?

Your doctor may order the following tests:

• Blood tests: To evaluate your general health
• Tissue cultures: This test is done to diagnose a bacterial or fungal infection in a wound that does not heal with treatment or when the ulcer is already at stage IV
• Tissue cultures may also be ordered to check for cancerous tissue in a chronic, nonhealing wound.

Usually, stage I and II bedsores heal within few weeks to months with conservative treatment of the wound and ongoing general care. Stage III and IV bedsores are more difficult to treat.

Treatment team:

• A multidisciplinary approach is necessary to address the various aspects of wound care. Members of your care team may include:
• A primary care physician who supervises your the treatment plan
• A physician specializing in wound care
• Nurses or medical assistants who provide both care and education for managing wounds
• A social worker who helps you and your family access appropriate resources and addresses emotional concerns related to long-term recovery
• A physical therapist who teaches exercises to improve mobility
• A dietitian who monitors your nutritional needs and recommends a proper diet
• A neurosurgeon, orthopedic surgeon or plastic surgeon, depending on the type of surgery if needed

Pressure reduction:

The first step in the treatment of a bedsore is reducing the pressure that has caused it. Strategies include the following:

Repositioning: If you have a pressure sore, you need regular repositioning and placement in correct positions.

If you use a wheelchair, try shifting your weight for every 15 minutes or so. Ask for help while repositioning every hour.

If you are bed-ridden, it is necessary to change positions every two hours. Try repositioning yourself using a device such as a trapeze bar if you have enough upper body strength.

Caregivers can use bed linens to help lift and reposition you so as to reduce friction and shearing.

Using support surfaces: Use specialized mattress, bed, and special cushions that help you lie down in a correct position, relieve pressure on any sores and protect vulnerable skin. If you are in a wheelchair, use a seat cushion made up of foam, or either air-filled or water filled.

Select the one that best suits your condition, body type, and mobility.

Cleaning and dressing of wounds: This helps in healing of the wound, and includes the following:

Cleaning: It is essential to keep the wounds clean to prevent infection.

If the affected skin is not broken as in a stage I wound, wash it gently with water and mild soap and pat it dry.

Open sores need to be cleaned with a saline solution every time the dressing is changed.

Applying dressings: A dressing facilitates healing by keeping the wound moist, acting as a barrier against infection, and by maintaining the surrounding skin dry.

Dressings may be films, gauzes, gels, foams, and treated coverings.

Your doctor will select a dressing based on a number of factors such as the size and severity of the wound, the amount of discharge, and the ease of placement and removal of the dressing.

Removal of damaged tissue: For proper healing to occur, the wound needs to be free of damaged, dead or infected tissue.

Removing this tissue or the process of debridement is accomplished with different methods, based on the severity of the wound, your overall health condition, and your treatment goals.

Surgical debridement involves cutting away the dead tissues.

Mechanical debridement loosens and removes the wound debris.

This may be accomplished using a pressurized irrigation device, low-frequency mist ultrasound or specialized dressings.

Autolytic debridement enhances our body's natural process of employing enzymes in the breakdown of dead tissue.

This method may be suitable for smaller, uninfected wounds, and uses special dressings to keep the wound moist and clean.

Enzymatic debridement involves an application of chemical enzymes and appropriate dressings to break down the dead tissue.

Other interventions that may be used are:

Pain management: Pressure ulcers can be painful.

Nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin IB, Advil, others) and naproxen (Aleve, others) may relieve pain.

These may be very helpful before or after repositioning, debridement procedures, and during dressing changes.

Topical pain medications are also used during debridement and dressing changes.

Antibiotics: Infected pressure sores that are unresponsive to other interventions may be treated with topical or oral antibiotics.

A healthy diet: To promote wound healing, your doctor or dietitian may recommend an increased intake of calories and fluids, a high-protein diet, and an increase in foods rich in vitamins and minerals.

You may be advised to take dietary supplements, such as vitamin C and zinc.

Management of incontinence: Urinary or bowel incontinence may lead to excess moisture and bacterial buildup on the skin, increasing the risk of infection.

Strategies include frequently scheduled help with urinating, frequent diaper changes, applying protective lotions on healthy skin, and use of urinary catheters or rectal tubes.

Muscle spasm relief: Spasm-related friction or shearing can cause or worsen bedsores.

Muscle relaxants such as diazepam (Valium), tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen (Gablofen, Lioresal) may suppress muscle spasms and help in the healing of the bedsores.

Negative pressure therapy (vacuum-assisted closure, or VAC): This kind of therapy uses a device that applies suction to a clean a wound. It may help in the healing of some types of pressure sores.

Surgery: A pressure sore that fails to heal with conservative treatment may require surgery.

The goals of surgical treatment include:

• Improving the hygiene and appearance of the sore,
• Prevention or treatment of infection,
• Reducing the loss of fluids through the wound,
• Lowering the risk of cancer

If you need surgery, the type of the procedure depends on the location of the wound and the presence of scar tissue from a previous operation.

Generally, most pressure sores are repaired by taking a pad of your own muscle, skin or other tissues to cover the wound as well as act as the cushion to the affected bone (flap reconstruction).

Bedsores are often easier to prevent than treat, but this does not mean that the process is uncomplicated.

Wounds may still develop even after appropriate and consistent preventive care.

Your doctor and other members of your health care team can help you in developing a good strategy whether it is personal care with at-home assistance, professional care at a hospital or some other situation.

The key step in the prevention of pressure sores is avoiding prolonged pressure on certain parts of your body, especially the pressure points.

This can be done by frequent repositioning to avoid stress on the skin and to minimize pressure on vulnerable areas.

Other strategies include taking good care of your skin, maintaining good nutrition, quitting smoking, and exercising daily.

Repositioning in a wheelchair: Consider the following recommendations for repositioning in a wheelchair:

Shift your weight frequently: If you sit in a wheelchair for a prolonged time, try shifting your weight once in every 15 minutes. Take help while repositioning about once in an hour.

If you can, try lifting yourself. If you possess enough upper body strength, perform wheelchair pushups that involve raising your body off from the seat by pushing on the arms of the chair.

A specialty wheelchair that allows you to tilt them can help relieve pressure. 

Use a cushion that relieves pressure: Use cushions to relieve pressure and ensure your body is well-positioned in the chair.

Various cushions are available, such as foam, gel, water filled, and air filled. A physical therapist can provide advice on placement of seat cushions, and their role in regular repositioning.

Repositioning in a bed: Consider the following recommendations while repositioning in a bed:

Reposition yourself frequently: Change your body position while lying down in a bed every two hours. Look into devices that help you reposition.

If you have enough upper body strength, try repositioning yourself with the help of a device called trapeze bar.

Caregivers can take the help of bed linens to lift and reposition you. This reduces friction and shearing.

Try a specialized mattress: Make use of special cushions, a foam mattress pad, an air-filled mattress or a water-filled mattress to help in positioning, relieving pressure and protecting vulnerable areas.

Your doctor may recommend an appropriate mattress or surface.

Adjust the elevation of your bed: If your hospital bed can be elevated at the head side, raise it to not more than 30 degrees.

This helps to prevent shearing. Use cushions as a protection to bony areas. Do not lie directly on your hip, instead, lie at an angle with cushions to support you at the back or front.

You may also place cushions to relieve pressure against and between the knees and ankles. You can cushion or ''float'' your heels by placing cushions below your calf area.

Skin care: Protection of skin is important to prevent pressure sores and to identify stage I sores at an early stage so that it can be treated before worsening.

Clean the affected skin: Clean the skin with mild soap and warm water or a no-rinse cleanser. Gently pat it dry.

Protect the skin: Apply talcum powder to protect skin that is likely to be exposed to excess moisture.

Apply moisturizing lotion so that your skin does not get too dry.

Change your bedding and clothing frequently.

Check for buttons on the clothing and wrinkles in the bedding that may irritate the skin.

Inspect the skin daily: Inspection of the skin daily helps to identify vulnerable areas or early signs of pressure sores.

You may need the help of a care provider to do a thorough skin inspection. If you are able to move, you may do this with the help of a mirror.

Manage incontinence to keep the skin dry: If you have bladder or bowel incontinence, follow certain steps to avoid exposure of your skin to moisture and bacteria.

These steps may include frequently scheduled help with urinating, frequent diaper changes, protective lotions on healthy skin, or urinary catheters/rectal tubes.

Choose a healthy diet: You may need to increase the amount of calories, proteins, vitamins and minerals in your diet.

You may need to take dietary supplements such as vitamin C and zinc. Drink plenty of fluids to keep your skin hydrated. Good hydration is the key factor to maintaining healthy skin.

Other strategies: Other important strategies that can decrease the risk of bedsores include the following:

Quit smoking. If you smoke, you should stop doing so. Talk to your doctor if you need help.

Be active: Reduced mobility is an important factor in causing pressure sores.

Daily exercise suitable to your abilities can help in maintaining healthy skin. A physical therapist will recommend an appropriate exercise program that improves blood flow, strengthens vital muscle tissue, stimulates your appetite and strengthens the body.

Lifestyle modifications are necessary in order to cope with Bedsores.

Successful treatment and prevention of further pressure sores require cooperation from you, your family members, and caregivers.

Issues that may need to be addressed by your doctor, the nursing staff, and a social worker include the following:

Community services: A social worker can help you identify a community group that provides services, education, and support to people who require long-term care for terminal illnesses.

End-of-life care: Physicians and nurses specializing in end-of-life care (palliative care) can assist a patient and his or her family in determining treatment goals, when the patient is nearing death.

At this time, goals may include management of pain and providing comfort.

Residential care: People with restricted movements who stay at residential or nursing care facilities will have a greater risk of developing pressure sores.

Family and friends of these people may contribute and work closely with the nursing staff to ensure proper preventive care.

People are at a greater risk of developing Bedsores if they are not able to change positions or have difficulty in moving themselves while being seated or lying down in a bed.

Immobility may be due to following reasons:

• Poor health or weakness
• Paralysis
• Serious injury or illness that requires bed rest or use of wheelchair
• Prolonged recovery period after surgery
• Sedation
• Coma

Other factors that can put you at an increased risk of pressure sores include:

Age: With advancing age, your skin becomes more fragile, thinner, delicate, less elastic, and drier. Additionally, elderly people usually produce new skin cells more slowly.

These factors make aging skin vulnerable to damage.

Lack of sensory perception: Injuries to the spinal cord and neurological disorders can result in a loss of sensation.

An inability to feel pain or discomfort can make you unaware of bedsores or the need to change your position.

Weight loss: Weight loss is a common consequence of prolonged illnesses. Muscle atrophy and wasting are common in people with paralysis.

The loss of fat and muscle underlying your skin results in lesser cushioning between your bones and the hard surface of a bed or a wheelchair.

Poor nutrition and hydration: We need enough fluids, calories, protein, vitamins, and minerals in our daily diet in order to maintain healthy skin and prevent the breakdown of tissues.

Poor eating habits or malnourishment may affect your skin, which can increase your risk. This also includes not drinking sufficient amount of fluids, especially water to keep your skin hydrated and avoid dryness.

Excessive moisture or dryness: Skin that is always moist due to excessive sweating or lack of bladder control is more likely to be injured.

Moisture increases the friction between skin and your clothing or bedding. Very dry skin also increases the friction.

Bowel incontinence: Bacteria from the stools can cause serious local infections and also cause life-threatening infections that may affect the entire body.

Medical conditions affecting blood circulation: Health conditions that affect your blood flow such as diabetes and vascular diseases further increase the risk of tissue damage.

Smoking: Smoking affects the blood flow and reduces the amount of oxygen present in the blood. Chronic smokers tend to develop more severe wounds with slower healing capacity.

Limited alertness: People in whom mental awareness is affected by a disease, trauma or medications, may not follow the actions required to prevent or care for pressure sores.

Muscle spasms: People who suffer from frequent muscle spasms or other involuntary muscle movements may be at an increased risk of pressure sores due to frequent friction and shearing action.

Complications of pressure ulcers include:

Sepsis: Sepsis results if bacteria gain entry into the blood circulation through a breach in the skin and spread throughout the body.

It progresses rapidly and is a life-threatening condition that causes organ failure.

Cellulitis: Cellulitis is an infection of the deeper skin layer and underlying soft tissues. It can cause severe pain, redness, and swelling.

People with associated nerve damage often cannot feel pain with this condition. Cellulitis may cause life-threatening complications.

Bone and joint infections: An infection from a pressure sore can spread into joints and bones.

Joint infections (septic arthritis) can cause damage to cartilage and tissue. Bone infections (osteomyelitis) may affect the function of joints and limbs.

Such infections may lead to life-threatening complications.

Cancer: A type of squamous cell carcinoma may develop in chronic, nonhealing wounds (Marjolin ulcer).

This cancer is aggressive and usually needs surgical treatment.