Understanding Bed Sores

Bed sores are damaged areas of skin and underlying tissue that develop due to prolonged or constant pressure on an area. They can form over hours to days and are most common in an area of bony prominence that does not have muscle or fat padding.

Bedsores are also called pressure ulcers, pressure sores, pressure injuries, pressure wounds, and decubitus ulcers.

General Overview of Risk Factors for Pressure Sores

People who spend most of their time sitting in a chair or lying in bed and have medical conditions that limit movement are at risk of developing bedsores. An example is someone with a spinal cord injury who uses a wheelchair. Other risk factors include malnutrition, smoking, fragile skin, and chronic health conditions like diabetes.

Importance of Awareness

It’s important to take precautions to prevent pressure sores and to treat pressure injuries as soon as possible. Untreated pressure sores can lead to serious health complications.

Symptoms of Bedsores

Common Sites of Pressure Sores

Pressure ulcers commonly occur due to sustained pressure on the skin covering bony areas. Ulcers are most common on parts of the body that are not well-padded with fat or muscle.

In people who spend a lot of time sitting, for example, wheelchair-users, bedsores are common in these locations:

Buttocks
Tailbone
Spine
Backs of arms and legs
Shoulder blades

In people who spend a lot of time lying in bed, pressure sores are common in these locations:

Back or sides of the head
Shoulder blades
Lower back
Tailbone
Hips
Behind the knees
Ankles
Heels

Warning Signs and Symptoms of Bedsores

Changes in skin color from the natural hue to red, blue, or purple. The color change in the skin remains for at least 30 minutes, even after pressure on the area is eased. People with darker skin tones may note the area is darker than surrounding skin.
Changes in skin texture. The skin in a pressure sore may feel soft and swollen.
Changes in skin temperature. A pressure sore can feel warmer or cooler to the touch compared to other areas of skin.
Drainage of a pus-like fluid that may have a bad smell

Stages of Pressure Ulcers: What is a Stage 4 Bed Sore?

Pressure injuries are categorized into stages based on the severity and degree of tissue damage:

Stage 1: A red, blue, or purple bruise-like area that can itch and feel warm to the touch.
Stage 2: A painful open sore resembling a blister that may have discolored surrounding tissue.
Stage 3: A deeper, crater-like open wound with dark skin at the edges.
Stage 4: The infected tissue spreads to nearby muscles, bones, or joints. A stage 4 decubitus ulcer can lead to serious bone infections called osteomyelitis and life-threatening sepsis.
Unstageable pressure sore: A stage 3 or 4 pressure injury that is covered with eschar (black-colored necrotic or dead skin) or slough (thick, white, creamy, gray, or black slimy tissue). The damage cannot be assessed and staged because of the covering.
Full-thickness deep tissue injury: A separation in the skin and a dark red, maroon, or purple deep wound filled with blood, exposed bone, and with or without nerve damage.

Causes of Bedsores

Contributing Factors

There are four main contributing factors to the development of a pressure injury:

Constant pressure on the area reduces blood flow to the skin and underlying tissue. Reduced blood flow limits the amount of oxygen and nutrients available to skin cells, leading to damage and skin loss.
Friction injuries occur due to the skin rubbing against clothes or bedding, especially if the person has fragile or moist skin.
Shearing occurs due to two surfaces moving in opposite directions. For instance, a person slides down in bed when the head of the bed is raised. In this case, their skin is moving downward against a stationary bed on a slope.
Moisture: Moisture from sweating or incontinence can lead to skin maceration and tissue breakdown, which can cause or worsen a pressure ulcer.

Who Is At Risk of Developing Pressure Sores?

As mentioned, people who spend a lot of time sitting in a chair or lying in bed and have problems moving or changing positions risk getting bedsores. Factors that can lead to an increased risk of pressure ulcers include:

Immobility or bed rest due to health conditions or injuries.
Lack of sensation due to spinal cord injuries or neurological disorders can prevent a person from feeling discomfort or pain or changing positions to relieve pressure.
Moisture from sweating or incontinence (stool or urine leakage), which makes the skin more prone to breakage and pressure ulcers
Vascular conditions (problems with blood supply) that can increase the risk of tissue damage from pressure sores
Poor nutrition and lack of adequate hydration. A nutritious diet is essential for healthy skin.
Age above 70
Excess body weight (due to extra pressure) or low body weight (due to lack of protective fat padding)

Note: Healthcare providers use risk assessment scales such as the Norton Scale or Braden Scale to assess a person’s risk of developing pressure sores based on criteria such as activity, mobility, friction, shear, moisture, sensory perception, and nutrition.

Prevention of Bedsores

Frequent changes in position to relieve pressure on any one area is the best way to prevent bedsores. In addition, you should take good care of your skin, eat a healthy diet, stay well hydrated, and quit smoking if you smoke.

Regular Repositioning

As noted, changing position while spending long periods in a bed or chair is critical to prevent pressure sores. Therefore, you should change position every 2 hours to shift weight and avoid putting pressure on any area for too long. For instance, if you’re a wheelchair user and have enough upper body strength, try doing wheelchair pushups every couple of hours to avoid prolonged pressure on your buttocks and spine. Adjust the head of your bed to no more than 30 degrees to prevent shearing.

Supportive Devices and Cushions

Wheelchair users can consider getting tiltable wheelchairs designed to prevent pressure injuries.

Consider getting specially designed mattresses, cushions, and other devices to ease pressure. Examples include special foam mattresses, gel-filled support surfaces, alternating pressure mattresses, foam cushions and air-filled cushions, and other devices like heel troughs, splints, and overlays.

Protective paddings, such as pillows and foam wedges, can be placed between or under the heels, ankles, and knees when supine or lying on one's side.

Proper Nutrition and Skin Care

Eat a healthy diet and stay well hydrated. This will ensure your body has all the nutrients it needs to keep your skin cells and other tissues healthy and fight infection.

In addition, practice good skin care by keeping your skin clean and dry and using moisture barrier creams. Change your clothing and bedding regularly. Avoid clothes or bedding with wrinkles or buttons that irritate skin by causing friction. Inspect your skin every day to identify skin damage early.

Treatment and Management Strategies

Consultation with a Team of Healthcare Professionals

It is important to consult a healthcare professional without delay if you notice or suspect a pressure injury. A team of healthcare providers is needed to manage pressure injuries, including:

A primary care physician will develop the treatment plan and coordinate medical care.
Wound care specialists, including physicians, nurses, and medical assistants.
Social workers to help you access resources for both mental and physical health concerns
Physical therapist to help you learn to move better in a bed or chair
Occupational therapist to ensure appropriate surfaces and recommend pressure-relieving devices
A licensed dietitian will make recommendations on a nutritious, balanced diet.
A dermatologist, a specialist in managing skin conditions
Other healthcare professionals, such as a vascular surgeon, orthopedic surgeon, neurosurgeon, or plastic surgeon, based on your needs.

Home Care Tips and Guidelines

Home care for pressure ulcers includes changing position every 2 hours and using pressure-relieving surfaces (mattress, cushions). In addition, you should eat a nutritious diet, stay well hydrated, and take good care of your skin.

Wound Care for Pressure Ulcers

To provide wound care for pressure sores, your healthcare team will:

Clean the wound: Consider gentle cleansing of the skin with saline (a saltwater solution) or a gentle cleanser, and patting it dry can help prevent infection.
Remove dead tissue: Removal of infected or dead tissue helps to promote healing. Tissue removal involves gently debriding the wound (cutting out damaged tissue) with surgical tools and flushing the wound with water.
Bandage the wound: Placement of a bandage (foam, gel, film, gauze, hydrocolloid) on the wound can help keep the sore moist and promote wound healing.

Medications for Pressure Sores

Your healthcare team may also offer other treatments for bedsores, such as:

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin) and naproxen sodium (Aleve) to manage pain and inflammation from decubitus ulcers
Topical pain medicines (gels, creams) applied locally to the wound
Topical antibiotics such as mupirocin, polymyxin B, and metronidazole for local wound infections

Adjunctive Therapies

Your healthcare team may recommend the following adjunctive therapies to promote wound healing in pressure sores:

Hyperbaric oxygen therapy
Negative-pressure wound therapy (vacuum-assisted closure [VAC])
Topical recombinant growth factors like platelet-derived growth factor and nerve growth factor
Cellular and tissue-based products like skin substitutes for chronic wounds
Electrical stimulation therapy
Electromagnetic therapy
Therapeutic ultrasound
Phototherapy
Heat therapy
Massage therapy

Note: Small studies have shown that these adjunctive therapies may help people with pressure injuries, but there isn’t enough scientific evidence to support their use in standard treatment protocols.

Surgical Interventions for Pressure Sores

Large pressure sores that do not heal with conventional treatments may require surgical interventions. These can include surgical repair with skin, muscle, or other tissues (flap surgery) or skin grafts to cover large wounds. A sore covered with a skin graft typically heals more quickly.

Complications and Life Expectancy

Potential Complications of an Untreated Pressure Ulcer

Left untreated, a pressure sore can lead to cellulitis (a bacterial infection of the deeper layers of the skin). The infection can also spread and cause bone and joint infections such as osteomyelitis and septic arthritis. A chronic, non-healing wound called a Marjolin ulcer is a squamous cell carcinoma of the skin. Rarely, skin ulcers can cause serious and life-threatening blood infections such as sepsis.

Common Questions and Concerns

How Long Does It Take for a Bedsore to Heal?

Depending on the severity, a bedsore can take several weeks or even months to heal.

Do Bedsores Go Away?

Yes, bedsores that are detected and treated quickly usually go away in a few weeks. Without treatment, pressure sores can worsen rapidly and lead to serious health complications.

What Is The Life Expectancy of Someone With a Bedsore?

The life expectancy of someone with a bedsore depends on the stage of the pressure injury, the underlying health status, and whether the bedsore is identified and treated promptly.

Generally speaking, patients with stage 1 and stage 2 bedsores usually recover in 2-3 weeks with timely treatment.

Severe sores can cause more serious complications and even death. Experts estimate that each year, about 60,000 people in the US die from complications related to pressure wounds. The risk of life-threatening complications increases with stage 3 and stage 4 bedsores. The average life expectancy for a person with a stage 4 bedsore is a few months, but some patients live for months or even years.

How To Stop Bed Sores From Getting Worse?

Seek prompt medical care to stop a bedsore from getting worse. Without professional medical treatment, pressure injuries can quickly get worse.

Improving Quality of Life For Affected Individuals

You can improve the quality of life of someone with pressure sores by:

Relieving pressure on the area by changing positions frequently and using supportive devices
Providing wound care as directed by the healthcare team
Preventing further pressure injuries by taking precautions to avoid prolonged pressure, especially on bony areas
Improving the person’s general health status by paying attention to nutrition and skincare.

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