Medically Reviewed by Dr Chua Zi Wei.
What is a Pressure Ulcer?
A pressure ulcer or bedsore is an injury to the skin and underlying tissues, particularly on “bony” areas such as the tailbone, hips, ankles, and heels; they occur due to prolonged pressure on the affected area.
The other terms people use to refer to bedsores are pressure sores, pressure injuries, and decubitus ulcers.
Generally, people who develop bedsores have conditions that limit their ability to move (unconsciousness, immobility, etc.). This means that they spend a significant amount of time lying in bed or sitting on a chair, which may limit the blood flow to certain areas of their body. People who wear a cast for a long time and those with inadequate capacity to sense pain are also at risk of experiencing bedsores.
Another important thing to note is this: some people develop bedsores in a matter of hours, not days. Furthermore, while many bedsores get better with treatment, others do not completely heal.
What Causes Pressure Ulcers?
Pressure ulcers occur because the affected skin and tissues underneath it don’t receive enough blood supply. This is a concern because blood carries oxygen and other nutrients that keep our cells healthy. Without an adequate blood supply, the tissues can become damaged and eventually diet.
Three factors contribute to the development of bedsores; they are:
Constant and significant pressure can impede blood flow to any part of the body. Think back to the times when you felt a tingling or numbing sensation after sitting down for too long. That sensation happened because the lack of movement affected your blood circulation.
People with conditions that limit their ability to move often experience bedsores on “bony” areas or those not well-padded by muscle or fat. Examples include:
- Back or sides of the head
- The rim of the ears
- Shoulder blades
- Back or sides of the knees
Another contributing factor is friction, the mechanical force occurring when our skin rubs against clothes, bedsheets, or linens. It doesn’t involve pressure, but repeated friction can make the skin (and the underlying tissues) more vulnerable to damage, especially if the area experiencing friction is often moist.
Last on our list of factors that contribute to the development of a bedsore is shearing, a mechanical force that happens when two surfaces move in the opposite direction.
In pressure ulcers, the “two surfaces” we refer to are the bones and the skin. Consider a patient in bed whose head is in a raised position. The force of gravity pulls the skeleton down, but because of friction, the surface of the skin remains attached to the bed. As a result, the blood vessels between the bones and skin become compressed and blood flow is interrupted.
Risk Factors for Bedsores
Many cases of bedsores occur in seniors because their skin is thinner and more vulnerable, but the following factors also increase someone’s risk of developing a pressure ulcer:
- Immobility – for instance, people who experienced paralysis due to stroke.
- Impaired ability to feel or respond to pain – this can happen to people with nerve damage due to diabetes.
- Incontinence – skin exposed to urine or faeces is more vulnerable to pressure sores.
- Problems in circulation – someone who has blood flow problems is also at risk.
- Malnutrition – undernutrition can affect the skin’s integrity; likewise, being obese means the tiny blood vessels receive added pressure which can impede blood flow. When malnutrition occurs with other factors like immobility, the risk of developing bedsores increases.
- Smoking – cigarette smoking damages the blood vessels; combined with reduced mobility, smoking also increases pressure ulcer risk.
Stages of Pressure Ulcers
Different pressure ulcer stages exhibit various signs and require diverse interventions. Below are the different pressure sore stages, their symptoms, and the kind of care required.
Stage 1 Pressure Ulcer
Individuals with stage 1 pressure ulcers do not have broken skin; but the affected area appears red. The area may also present a different temperature and texture from the surrounding area.
If you see stage 1 pressure ulcer, the following care instructions will help:
- Remove pressure from the area. One of the best ways to do this is to change position.
- Inspect for other contributing factors and remove them where possible.
- Wash the area with a gentle cleanser and pat it dry.
- Stay hydrated and ensure proper nutrition with vitamins and minerals necessary for wound healing (vitamin C, iron, zinc, etc.)
- Continue inspecting the area twice daily.
- Contact your healthcare provider right away if the area does not show signs of improvement after 2 to 3 days.
Stage 2 Pressure Ulcer
For stage 2 pressure ulcers, the topmost layer of the skin, called the epidermis, is already broken, resulting in a shallow open ulcer with a red pink wound bed, without slough.
- Follow the steps for stage 1 pressure ulcer care, especially the removal of any pressure.
- Next, call your healthcare provider right away because an open wound may require different care or a specific kind of medication.
- Generally, clean the wound with a saline solution and cover it with a bandage to retain moisture while keeping the surrounding area dry. A bandage also helps protect it against infection.
Stage 3 Pressure Ulcer
Stage 3 pressure ulcer affects the dermis, the layer underneath the epidermis. Subcutaneous fat is visible but the bones, muscles and tendons are not affected yet.
- Call your healthcare provider right away to receive instructions on proper wound care.
- Look for signs of infection, including leaking pus or greenish discharge, redness, odour, and fever. Report these symptoms to the doctor as well.
- Ask the doctor about a special, pressure-relieving mattress.
Stage 4 Pressure Ulcer
Stage 4 bedsore is extensive, often involving a large, deep, crater sore. At this point, the wound may be deep enough to affect the tendons, muscles and bones. There might also be necrosis or tissue death involved.
- Remove any pressure and contact a doctor right away as stage 4 bedsores might require wound debridement (removal of dead tissues) or advanced wound treatment.
In cases where the wound has a full-thickness tissue loss and its base is covered with eschar or slough, the pressure ulcer staging no longer applies; we then say that the bedsore is unstageable. Slough is a wet material that can be yellow, tan, brown, or grey. Eschar is dead tissue that is usually brown or black.
Treatment and Care for Pressure Sores
Interventions for pressure sores, regardless of stages, should be unique to the individual. This is because even two people with the same bedsore stage may exhibit different symptoms.
A comprehensive wound assessment would be important. Subsequently, doctors recommend the following treatment strategies:
- Wound cleansing and debridement.
- Use solutions with antimicrobials properties for infected wounds
- Debridement of necrotic or infected tissue
- Appropriate wound dressings based on the characteristic of the wound, self care abilities of the individual and availability of dressing solutions.
- Antibiotic treatment if there is signs and symptoms of infection of the wound such as
- Delayed wound healing
- Wound breakdown
- Increased exudates
- Increased warmth
- Increased pain
Potential Complications of Untreated Bedsores
Left untreated, the following complications may occur:
- Sepsis, or severe infection that has already spread in the bloodstream
- Cellulitis or swelling and inflammation of the involved tissues
- Infections affecting the bones or joints
- Abscess or the collection of pus
- Squamous carcinoma, a type of cancer
Pressure Ulcer Prevention
Identify risk factors of pressure injuries such as
- Lack of sensory perception.
- Poor nutrition and hydration.
- Medical conditions affecting blood flow.
- At least daily skin inspection and pressure points assessment. Skin redness, change in skin temperature, edema may be indicating the early pressure injury
- Keeping the skin clean and appropriately hydrated
- Cleansing the skin immediately after episodes of incontinence
- Avoid usage of alkaline soaps and cleansers
- Use skin barrier products to protect skin from moisture
- Avoid rubbing skin that is at risk of pressure injuries.
- Use high absorbency incontinence products to protect the skin of individuals at risk of pressure injuries who have urinary incontinence.
- Use of soft silicon foam dressing to protect skin at risk of pressure injuries.
- Nutritional assessment for individuals at risk by dietitian
- Optimize energy and protein intake
Repositioning and Mobilization
- Use appropriate support surfaces eg Ripple Mattress
- Repositioning all individuals with or at risk of pressure injuries on an individualized schedule to relieve and redistribute pressure
- Promote seating out of bed on a chair or wheelchair.
- Early mobilization of patients whenever possible.
Are You Worried About Bedsores?
Do you need help with bedsore prevention training? Our nurses here at Homage can help you. They can give you a visit at home and teach you strategies to reduce your or your family member’s risk of developing decubitus ulcers.
If you notice signs of stage 2 pressure ulcers, talking to a healthcare provider is necessary. That’s because open wounds require personalised care. Consider booking an appointment with a doctor who can treat the wound and give you the proper care instructions.
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- Bedsores. (n.d.). Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved March 28, 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/bedsores
- Pressure sores. (n.d.). Better Health Channel – Better Health Channel. Retrieved March 28, 2021, from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pressure-sores#grades-of-pressure-sores
- Pressure ulcers (pressure sores). (2017, October 23). nhs.uk. Retrieved March 28, 2021, from https://www.nhs.uk/conditions/pressure-sores/
- Recognizing and treating pressure sores. (n.d.). Model Systems Knowledge Translation Center (MSKTC). Retrieved March 28, 2021, from https://msktc.org/sci/factsheets/skincare/Recognizing-and-Treating-Pressure-Sores