Bedsores (pressure ulcers)
Bedsores — also called pressure ulcers and decubitus ulcers — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.
People most at risk of bedsores are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.
Bedsores can develop quickly. Most sores heal with treatment, but some never heal completely. You can take steps to help prevent bedsores and aid healing.
Warning signs of pressure ulcers are:
- Unusual changes in skin color or texture
- Pus-like draining
- An area of skin that feels cooler or warmer to the touch than other areas
- Tender areas
Bedsores fall into one of several stages based on their depth, severity and other characteristics. The degree of skin and tissue damage ranges from red, unbroken skin to a deep injury involving muscle and bone.
Common sites of pressure sores
For people who use a wheelchair, pressure sores often occur on skin over the following sites:
- Tailbone or buttocks
- Shoulder blades and spine
- Backs of arms and legs where they rest against the chair
For people who are confined to a bed, common sites include the following:
- Back or sides of the head
- Shoulder blades
- Hip, lower back or tailbone
- Heels, ankles and skin behind the knees
When to see a doctor
If you notice warning signs of a bedsore, change your position to relieve the pressure on the area. If you don't see improvement in 24 to 48 hours, contact your doctor.
Seek immediate medical care if you show signs of infection, such as a fever, drainage from a sore, a sore that smells bad, or increased redness, warmth or swelling around a sore.
Bedsores are caused by pressure against the skin that limits blood flow to the skin. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores.
Three primary contributing factors for bedsores are:
Pressure. Constant pressure on any part of your body can lessen the blood flow to tissues. Blood flow is essential to delivering oxygen and other nutrients to tissues. Without these essential nutrients, skin and nearby tissues are damaged and might eventually die.
For people with limited mobility, this kind of pressure tends to happen in areas that aren't well-padded with muscle or fat and that lie over a bone, such as the spine, tailbone, shoulder blades, hips, heels and elbows.
- Friction. Friction occurs when the skin rubs against clothing or bedding. It can make fragile skin more vulnerable to injury, especially if the skin is also moist.
- Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone might stay in place — essentially pulling in the opposite direction.
People are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Risk factors include:
- Immobility. This might be due to poor health, spinal cord injury and other causes.
- Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of warning signs and the need to change position.
- Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.
- Medical conditions affecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage.
Complications of pressure ulcers, some life-threatening, include:
- Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause warmth, redness and swelling of the affected area. People with nerve damage often do not feel pain in the area affected by cellulitis.
- Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) can reduce the function of joints and limbs.
- Cancer. Long-term, nonhealing wounds (Marjolin's ulcers) can develop into a type of squamous cell carcinoma
- Sepsis. Rarely, a skin ulcer leads to sepsis.
You can help prevent bedsores by frequently repositioning yourself to avoid stress on the skin. Other strategies include taking good care of your skin, maintaining good nutrition and fluid intake, quitting smoking, managing stress, and exercising daily.
Tips for repositioning
Consider the following recommendations related to repositioning in a bed or chair:
- Shift your weight frequently. If you use a wheelchair, try shifting your weight about every 15 minutes. Ask for help with repositioning about once an hour.
- Lift yourself, if possible. If you have enough upper body strength, do wheelchair pushups — raising your body off the seat by pushing on the arms of the chair.
- Look into a specialty wheelchair. Some wheelchairs allow you to tilt them, which can relieve pressure.
- Select cushions or a mattress that relieves pressure. Use cushions or a special mattress to relieve pressure and help ensure your body is well-positioned. Do not use doughnut cushions, as they can focus pressure on surrounding tissue.
- Adjust the elevation of your bed. If your bed can be elevated at the head, raise it no more than 30 degrees. This helps prevent shearing.
Tips for skin care
Consider the following suggestions for skin care:
- Keep skin clean and dry. Wash the skin with a gentle cleanser and pat dry. Do this cleansing routine regularly to limit the skin's exposure to moisture, urine and stool.
- Protect the skin. Use plain talcum powder to protect skin at friction points. Apply lotion to dry skin. Change bedding and clothing frequently if needed. Watch for buttons on the clothing and wrinkles in the bedding that irritate the skin.
- Inspect the skin daily. Look closely at your skin daily for warning signs of a pressure sore.
Your doctor will look closely at your skin to determine whether you have a pressure ulcer and how bad the damage is. He or she will try to assign a stage to the wound. Staging helps determine what treatment is best for you. He or she might also order a blood test to assess your general health.
Questions from the doctor
Your doctor might ask questions such as:
- When did the pressure sore first appear?
- What is the degree of pain?
- Have you had pressure sores in the past?
- How were they managed, and what was the outcome of treatment?
- What kind of care assistance is available to you?
- What is your routine for changing positions?
- What medical conditions have you been diagnosed with, and what is your current treatment?
- What is your normal daily diet and fluid intake?
Treating pressure ulcers involves reducing pressure on the affected skin, caring for the wounds, controlling pain, preventing infection and maintaining good nutrition.
Addressing the many aspects of wound care usually requires a multidisciplinary approach. Members of your care team might include:
- A primary care physician who oversees the treatment plan
- A physician or nurse specializing in wound care
- Nurses or medical assistants who provide both care and education for managing wounds
- A social worker who helps you or your family access resources and who addresses emotional concerns related to long-term recovery
- A physical therapist who helps with improving mobility
- An occupational therapist who helps to ensure appropriate seating surfaces
- A dietitian who monitors your nutritional needs and recommends a good diet
- A doctor who specializes in conditions of the skin (dermatologist)
- A neurosurgeon, orthopedic surgeon or plastic surgeon
The first step in treating a bedsore is reducing the pressure and friction that caused it. Strategies include:
- Repositioning. If you have a pressure sore, turn and change your position often. How often you reposition depends on your condition and the quality of the surface you are on. Generally if you use a wheelchair, try shifting your weight every 15 minutes or so and change positions every hour. If you're in a bed, change positions every two hours.
- Using support surfaces. Use a mattress, bed and special cushions that help you sit or lie in a way that protects vulnerable skin.
Cleaning and dressing wounds
Care for pressure ulcers depends on how deep the wound is. Generally, cleaning and dressing a wound includes the following:
- Cleaning. If the affected skin is not broken, wash it with a gentle cleanser and pat dry. Clean open sores with water or a saltwater (saline) solution each time the dressing is changed.
- Putting on a bandage. A bandage speeds healing by keeping the wound moist. This creates a barrier against infection and keeps the surrounding skin dry. Bandage choices include films, gauzes, gels, foams and treated coverings. You may need a combination of dressings.
Removing damaged tissue
To heal properly, wounds need to be free of damaged, dead or infected tissue. Removing this tissue (debridement) is accomplished with a number of methods, such as gently flushing the wound with water or cutting out damaged tissue.
Other interventions include:
- Drugs to control pain. Nonsteroidal anti-inflammatory drugs — such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) — might reduce pain. These can be very helpful before or after repositioning and wound care. Topical pain medications also can be helpful during wound care.
- Drugs to fight infection. Infected pressure sores that aren't responding to other interventions can be treated with topical or oral antibiotics.
- A healthy diet. Good nutrition promotes wound healing.
- Negative pressure therapy. This method, which is also called vacuum-assisted closure (VAC), uses a device to clean a wound with suction.
A large pressure sore that fails to heal might require surgery. One method of surgical repair is to use a pad of your muscle, skin or other tissue to cover the wound and cushion the affected bone (flap reconstruction).
Coping and support
People with pressure sores might experience discomfort, pain, social isolation or depression. Talk with your care team about your needs for support and comfort. A social worker can help identify community groups that provide services, education and support for people dealing with long-term caregiving or terminal illness.
Parents or caregivers of children with pressure ulcers can talk with a child life specialist for help in coping with stressful health situations.
Family and friends of people living in assisted living facilities can be advocates for the residents and work with nursing staff to ensure proper preventive care.