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Overview

Pressure sores, also called bed sores or pressure ulcers are damage to the skin and underlying tissue which results from sustained pressure that cuts off circulation to parts of the body. Decubitus ulcers are pressure sores that occur when someone lies on his or her back for long periods of time. This can be because of physical or mental limitations.

Someone who is bedridden, perhaps because of an injury or a stroke, runs a high risk of developing a pressure sore. Seniors are especially vulnerable. In people who must lie in bed for long periods of time, most pressure sores form where the skin is trapped between a bone and the resting surface such as on the lower back below the waist, the hip bone, and on the heels. They can also develop on the knees, ankles, shoulder blades, back of the head, and spine. Some studies suggest that 3 to 10 percent of hospitalized patients have pressure sores, with two-thirds of these over the age of 70.

An individual who is left to sit in a wheelchair is also extremely vulnerable because he or she is unable to feel the irritation or building pressure that comes with not being able to change position from time to time.

Pressure sores are serious problems that can lead to pain, a longer stay in the hospital or nursing home, and slower recovery from health problems. Fortunately, in most cases, they can be prevented.

Symptoms

Doctors categorize bed sores according to the severity of symptoms. For example, in Stage 1, the symptoms are far less severe than in Stage 4. Depending on how severe they are, they can appear as red areas, blisters, large scabs or, worst of all, deep holes or craters.

• Stage 1: skin redness that does not turn white with pressure (approximately one half of all pressure sores)
• Stage 2: a scrape that results from loss of the outer skin layers (one third of all pressure sores)
• Stage 3: a shallow crater from loss of the skin and some of the tissue below the skin
• Stage 4: a deep crater from damage extending into muscle or bone

The higher the stage, the longer symptoms remain. While about 75% of stage 2 sores heal within 8 weeks, only 62% of stage 4 pressure sores ever heal, and only 52% heal within one year.

Causes

Our nerves are sending us signals all the time. Some of these signals tell us there's too much pressure on that bone you'd better change your position a bit'. But these signals are meaningless if you are unable to move or if your brain isn't working properly to process the message. Consequently you lie in the same spot and the pressure on the skin and underlying tissue builds even more. The sustained force squeezes tiny blood vessels closed, cutting off circulation and starving the skin of oxygen and other nutrients. If the pressure is not relieved, the tissue dies and a pressure sore forms.

It doesn't take a long time for this to happen. A person can get a pressure sore from lying immobile in bed for just a couple of hours. It takes even less time for someone who is sitting in a wheelchair because the pressure is greater. Left untreated, the skin may break open and become infected, leading to serious, even deadly complications.

You are a higher risk of developing pressure sores if you are:

Confined to a bed or chair.

If you must stay in bed, a chair, or a wheelchair, the risk of getting a pressure ulcer can be high.

Not able to move.

If you cannot change positions without help, you are at great risk. People who are in a coma or who are paralyzed or have a hip fracture are at special risk.

Cannot control your bowel or bladder.

If you cannot keep your skin free of urine, stool, or perspiration, you have a higher risk. These sources of moisture may irritate the skin.

Eating poorly.

If you cannot eat a balanced diet, your skin may not be properly nourished. Pressure sores are more likely to form when skin is not healthy.

Not fully aware.

When mental awareness is lowered, a person cannot act to prevent pressure ulcers. Mental awareness can be affected by health problems, medications, or anesthesia.

Treatment

Left untreated pressure sores can have serious and even life-threatening complications. The most serious complication is blood poisoning. Other types of infections are also common. For about 25% of people with non-healing pressure sores, the underlying bone is involved in the infection. Pressure sores can also serve as sources of serious infections by bacteria that are resistant to normal antibiotics. Other complications include pain and depression, both of which have been linked to slow wound healing.

A pressure sore will not heal unless underlying causes are identified and effectively managed. Whenever pressure sores develop, they should be examined by a healthcare provider. The size, number, location, and depth of pressure ulcers should be recorded. Any evidence of infection (e.g., a milky drainage, fever, foul odor, or surrounding redness of the skin) should be noted. Your healthcare providers may gently push around the edge of the ulcer and probe it with a clean cotton swab to determine how deep it is. Blood tests or X-rays may also be needed to gauge infection or involvement of underlying bone.

Any underlying health conditions or barriers that prevent someone from being able to move around should be corrected or managed.

Sometimes, more specific treatments are needed to encourage and speed the healing of pressure ulcers. For example, dead tissue can support infection and prevent healing, so it needs to be removed through a process called debridement. Debridement can be done by cutting away the dead tissue, by mechanically removing it through scrubbing or irrigation, or by dissolving it with enzyme preparations. Your doctor will select a debridement method based on your health condition, and on the condition of the ulcer and whether it is infected.

Various types of dressings are used to absorb drainage and promote the healing of pressure sores. Wound cleansing and dressing changes are two of the most important methods for minimizing infection. Cleansing the wound and changing the dressing more often is particularly important if there is pus or foul-smelling drainage that indicates infection in the area.

If the pressure sore is severe, surgical repair may be needed. However, surgically treated sores tend to recur, especially if underlying problems are not corrected.

Antibacterial drugs may be used if the sore is not healing or it continues to ooze after 2 weeks of proper cleansing and bandage changes. Some antibacterial preparations can be applied directly to the skin. Antibiotics given by mouth or injection are needed for those who have blood poisoning or infections in the skin or underlying bone. Antibiotics are also given to prevent diseased heart valves from getting infected, or when the ulcer needs surgical repair.

Prevention

The best way to deal with pressure ulcers is to prevent them before they start.

• Your skin should be inspected at least once a day. Pay special attention to any reddened areas that remain after you have changed positions and the pressure has been relieved. This inspection can be done by yourself or your caregiver. The goal is to find and correct problems before pressure ulcers form.

• Your skin should be cleaned as soon as it is soiled. A soft cloth or sponge should be used to reduce injury to skin.

• Take a bath when needed for comfort or cleanliness. If a daily bath or shower is preferred or necessary, additional measures should be taken to minimize irritation and prevent dry skin. When bathing or showering, warm (not hot) water and a mild soap should be used. To prevent dry skin apply creams or oils.

• Avoid cold or dry air.

• Minimize moisture from urine or stool, perspiration, or wound drainage. When moisture cannot be controlled:

1. 1. Pads or briefs that absorb urine and have a quick drying surface that keeps moisture away from the skin should be used.
   2. A cream or ointment to protect skin from urine, stool, or wound drainage may be helpful.

• Avoid massage of your skin over bony parts of the body. Massage may squeeze and damage the tissue under the skin and make you more likely to get pressure ulcers.

• Limit pressure over bony parts by changing positions or having your caregiver change your position.

1. If you are in bed, your position should be changed at least every 2 hours.
2. If you are in a chair, your position should be changed at least every hour. (If you are able to shift your own weight, you should do so every 15 minutes while sitting.)

If you are confined to bed:

1. A special mattress that contains foam, air, gel, or water helps to prevent pressure ulcers. The cost and effectiveness of these products vary greatly. Talk to your health care provider about the best mattress for you.

2. The head of the bed should be raised as little and for as short a time as possible if consistent with medical conditions and other restrictions. When the head of the bed is raised more than 30 degrees, your skin may slide over the bed surface, damaging skin and tiny blood vessels.

3. Pillows or wedges should be used to keep knees or ankles from touching each other.

4. Avoid lying directly on your hip bone when lying on your side. Also, a position that spreads weight and pressure more evenly should be chosen -- pillows may also help.

5. If you are completely immobile, pillows should be put under your legs from mid-calf to ankle to keep heels off the bed. Never place pillows behind the knee.

If you are in a chair or wheelchair:

1. Foam, gel, or air cushions should be used to relieve pressure. Ask your health care provider which is best for you. Avoid donut-shape cushions because they reduce blood flow and cause tissue to swell, which can increase your risk of getting a pressure ulcer.

2. Avoid sitting without moving or being moved.

3. Good posture and comfort are important.

Nutrition

• Eat a balanced diet. Protein and calories are very important. Healthy skin is less likely to be damaged.

• If you are unable to eat a normal diet, talk to your health care provider about nutritional supplements that may be desirable.