Learn More About Pressure Prevention
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Pressure sores (bedsores, decubitus ulcers, pressure ulcers) are areas of skin damage resulting from a lack of blood flow due to pressure.
Sores often result from pressure but may also result from pulling on the skin or friction, particularly over bony areas.
The diagnosis is usually based on a physical examination.
Treatment includes cleansing, removal of pressure from the affected area, special dressings, and, sometimes, surgery.
Pressure sores can occur in people of any age who are bedbound, chairbound, or unable to reposition themselves. They are more common among older people. They tend to occur over bony projections where pressure on skin can be concentrated, such as over the hip bones, tailbone, heels, ankles, and elbows. They occur where there is pressure on the skin from a bed, wheelchair, cast, splint, or other hard object .Pressure sores lengthen the time spent in hospitals or nursing homes and increase the cost of care. Pressure sores can be life threatening if they are untreated or if underlying health conditions prevent them from healing.
Common Sites for Pressure Sores
Causes that contribute to the development of pressure sores include:
Pressure on skin, especially when over bony areas, reduces or cuts off blood flow to the skin. If blood flow is cut off for more than 1 or 2 hours, the skin dies, beginning with its outer layer (epidermis). The dead skin breaks down and forms an open sore (ulcer). Most people do not develop pressure sores because they constantly shift position without thinking, even when they are asleep. However, some people cannot move normally and are therefore at greater risk of developing pressure sores. They include people who are paralyzed, comatose, very weak, sedated, or restrained. Paralyzed and comatose people are at particular risk because they also may be unable to move or feel pain (pain normally motivates people to move or to ask to be moved).
Traction also reduces blood flow to the skin. Traction occurs when the skin is stretched by being wedged against something or when it sticks to something, often bed linens. When the skin is stretched, the effect is much like pressure.
Friction can lead to or worsen pressure sores. Repeated friction may wear away the top layers of skin. Such skin friction may occur if people are pulled repeatedly across a bed.
Moisture can increase skin friction and weaken or damage the protective outer layer of skin if the skin is exposed to it a long time. For example, the skin may be in prolonged contact with perspiration, urine, or feces.
Inadequate nutrition increases the risk of developing pressure sores and slows the healing process of sores that do develop. Malnourished people may not have enough body fat to pad the skin and bones or to keep the blood vessels from being squeezed shut. Also, skin repair is impaired in people whose diets are deficient in protein, vitamin C, or zinc.
Did You Know...
Inadequate nutrition increases the chances of developing pressure sores and slows the healing of sores that do develop.
Repositioning people who cannot move themselves at least every 1 to 2 hours can help prevent pressure sores.
For most people, pressure sores cause some pain and itching. However, in people whose senses are dulled, even severe sores may be painless.
Pressure sores are categorized into four stages according to the severity of damage:
Stage I: Redness and inflammation
Stage II: Some shallow skin loss, including abrasions, blisters or both
Stage III: Full-thickness skin loss down to the layer of fat.
Stage IV: Full-thickness skin loss with exposure of underlying muscle, tendon, or bone
Pressure sores do not always progress from mild to severe stages. Sometimes the first noticeable sign is a late-stage sore.
If pressure sores become infected, they may have an unpleasant odor. Pus may be visible in or around the sore. The area around the pressure sore may become red or feel warm, and pain may worsen if the infection spreads to the surrounding skin (causing cellulitis). Infection delays healing of shallow sores and can be life threatening in deeper sores. Infection can even penetrate the bone (osteomyelitis), requiring weeks of treatment with antibiotics. In the most severe cases, infection can spread into the bloodstream (sepsis), causing fever or shaking chills.
Spotlight on Aging
Aging itself does not cause pressure sores. But it causes changes in tissues that make pressure sores more likely to develop. As people age, the outer layers of the skin thin. Many older people have less fat and muscle, which helps absorb pressure. The number of blood vessels decreases, and blood vessels rupture more easily. All wounds, including pressure sores, heal more slowly.
Certain conditions make pressure sores more likely to develop:
Being unable to move normally because of a disorder such as stroke
Having to stay in bed for a long time, for example, because of surgery
Being excessively sleepy (such people are less likely to change position or ask someone to reposition them)
Losing sensation because of nerve damage (such people do not feel discomfort or pain, which would prompt them to change positions)
Becoming less responsive to what is happening in and around them, including their own discomfort or pain, because of a disorder such as dementia
Doctors can usually diagnose pressure sores by doing a physical examination. A doctor or nurse usually measures the size and depth of a sore to determine its stage and plan treatment.
If the damage is severe, radionuclide bone scanning or gadolinium-enhanced MRI (magnetic resonance imaging) may be done to check whether infection has spread from the sore to bone—a disorder called osteomyelitis. To diagnose osteomyelitis, doctors may need to take a small sample (biopsy) of bone to see if bacteria grow from it (culture).
Prevention is the best strategy for dealing with pressure sores. In most cases, pressure sores can be prevented by meticulous attention from all caregivers, including nurses, nurses' aides, and family members. Close daily inspection of a bedridden or chairbound person's skin can detect early redness or discoloration. Any sign of redness or discoloration at pressure areas is a signal that the person needs to be repositioned and kept from lying or sitting on the discolored area until it returns to normal.
Because shifting position is necessary to keep the blood flowing to the skin, oversedation should be avoided and activity encouraged. People who cannot move themselves should be repositioned every 2 hours if they are in bed and every hour if they are in a chair—more often if possible. The skin must be kept clean and dry because moisture increases the risk of developing pressure sores. Dry skin is less likely to stick to fabrics and cause friction or traction. For people confined to bed, sheets should be changed frequently to make sure they are clean and dry. Applying noncaking body powder to skin in areas where two parts of the body press against each other (such as the buttocks and groin) can help keep the skin in these areas dry.
Bony projections (such as heels and elbows) can be protected with soft materials, such as foam wedges and heel protectors. Donut-shaped devices and sheepskins should be avoided as they only shift pressure or friction from one vulnerable site to another. Special beds, mattresses, and seat cushions can be used to reduce pressure in people who are wheelchair-bound or bedridden. These products can reduce pressure and offer extra relief. A doctor or nurse can recommend the most appropriate mattress surface or seat cushion. It is important to remember that none of these devices eliminate pressure completely or are a substitute for frequent repositioning.
Treating a pressure sore is much more difficult than preventing one. The main goals of treatment are to relieve pressure on the sores, keep them clean and free of infection, and provide adequate nutrition. Adequate nutrition is important in helping pressure sores heal and in preventing new sores from forming. A well-balanced, high-protein diet is recommended as well as a daily high-potency vitamin and mineral supplement. Supplemental vitamin C and zinc may help with healing as well. Electrical stimulation, heat therapy, massage therapy, and hyperbaric O2 therapy have not proven helpful.
In the earliest stage, pressure sores usually heal by themselves once pressure is removed. When the skin is broken, a doctor or nurse considers the location and condition of the pressure sore when recommending a dressing. Film (see-through) dressings help protect early-stage pressure sores and allow them to heal more quickly. Hydrocolloid (oxygen- and moisture-retaining) patches protect, keep the skin appropriately moist, and provide a healthy environment for deep sores. Other types of dressings may be used for deeper sores, those that ooze a lot of fluids, and those that are infected.
If the sore appears infected or oozes, rinsing with saline and dabbing gently with a gauze pad are helpful. A doctor may need to remove (debride) dead tissue with a scalpel or a chemical solution. Removal of dead tissue is usually painless, because pain is not felt in dead tissue. Some pain may be felt because healthy tissue is nearby. Health care practitioners may flood (irrigate) the sore, particularly its deep crevices, with a sterile solution to help clean away hidden debris.
Sometimes a bed that circulates air (an air-fluidized bed) is used in hospitals and nursing homes. This special bed helps reduce or redistribute pressure on the body.
Deep pressure sores are difficult to treat. Sometimes they require skin and muscle flaps, in which healthy, thicker tissue with a good blood supply is surgically repositioned to cover the damaged area. This type of surgery is not always successful, however, especially for frail older people who are malnourished. Often, when infections develop deep within a sore, antibiotics are given. When bones beneath a sore become infected, the bone infection (osteomyelitis) is extremely difficult to cure and may spread through the bloodstream, requiring many weeks of treatment with an antibiotic (see Bone and Joint Infections: Osteomyelitis).
Last full review/revision October 2008 by Daniel W. Collison, MD
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