Pressure sores, also called bed sores, or decubitus ulcers, are the result of tissue damage that is caused by pressure against the skin, the friction of bedding or other materials against the skin, and/or shear forces created when the skin is moved one direction and underlying tissues are moved in the opposite direction as a patient moves or is moved. Pressure sores occur most frequently in areas where the bones are close to the skin such as the hips, tailbone, shoulders, heels, even the back of the head, when a person is confined to a bed for an extended period, but they can also occur on the buttocks and hips if a person sits for lengthy periods as well. Once the tissue has been damaged, sores or wounds of this type are difficult to heal and are very painful for the patient.
Even an otherwise healthy person is at risk for developing a pressure sore if left in bed or a wheelchair for example without changing positions and other care, but the following factors significantly increase the risk of an individual developing a pressure ulcer:
- Individuals that cannot reposition themselves in bed or a chair to alleviate the pressure that builds under the skin. Even if a person has some ability to move themselves, decreased mobility means they may generate friction or shear forces as they attempt to move themselves in bed or a chair.
- Individuals with decreased sensation or neurological impairment may not feel the discomfort of pressure, friction, or shear and will not move themselves as frequently as they should to alleviate discomfort and prevent tissue damage.
- Individuals that are incontinent have a greater risk of developing a sore or wound because moist skin macerates or breaks down more rapidly and body fluids irritate the skin. Finally, if the skin is broken, even slightly, the risk of infection is magnified due to contact with urine and/or feces.
- Similarly, sweat or humidity also increases an individual’s risk for pressure sores.
- Individuals with poor circulation are also at increased risk for developing a pressure sore.
Nutrition and hydration are important for the health of the skin, so individuals that do not eat well or that have difficulty staying hydrated are at an increased risk.
Pressure sores are classified by the stage of development and unless other factors make a thorough examination of the sore or wound extremely difficult or impossible they usually fall into one of the following stages:
- Stage I – In a stage I sore, the skin will not be broken, but the presence of tissue damage will be indicated by skin redness that does not subside once pressure has been removed. The skin may differ in temperature from the surrounding skin and the area may be painful for the patient. The damage beneath the skin may be more severe than can be determined because the skin is still intact.
- Stage II – In a stage II sore, the skin shows evidence of damage, but only the skin is damaged. The sore may appear as an abrasion or a blister at the surface and the damage beneath the skin may be more extensive.
- Stage III – A stage III sore means the tissue damage extends through the full thickness of the skin and into the subcutaneous tissue. Because subcutaneous tissue is not as vascular as other tissue, a stage III sore can be very difficult to heal and again the sore may be much larger than can been seen from the surface.
- Stage IV – A stage IV sore involves damage to muscle, tendons, ligaments, and even bone.
The most effective and least expensive way to deal with pressure sores is to take steps to prevent them from occurring in the first place. A wound or sore prevention program should apply to every patient and health care practitioner in a facility and should include some or all of the following considerations.
- Bedding and seating surfaces should spread pressure out across the entire surface in contact with them rather than allow pressure to build under the bony prominences.
- The surfaces should also allow the skin to ‘breathe’. For example, allowing a patient to sit directly on the vinyl seat of a wheelchair can keep the skin moist around the buttocks and hips and a relatively inexpensive wheelchair cushion constructed of pressure relieving padding with a moisture wicking cover can prevent sores.
- Mattresses, mattress overlays, and seat cushions may feature differing densities or even cut out sections so that pressure is not applied to the areas where the bones are closest to the skin.
- Heel or elbow splints or braces that alleviate pressure on those areas can be placed on individuals at increased risk.
- Wheelchair padding, support, or a lap tray could be used to prevent patients from sliding down when seated which increases friction and shear.
- Patient lifts or friction reducing devices, such as slide sheets, should be used to reposition patients rather than simply sliding them up in bed or a wheelchair.
- Patients need to be repositioned regularly to allow the blood to flow to areas that have been under pressure so that proper oxygen levels can be restored and pressure can be relieved.
- Washable or disposable bed pads or undergarments that capture moisture and hold it away from the skin should be used for patients that are incontinent.
Understanding the factors that increase the likelihood of pressure sores occurring, being able to identify the earliest indicators of developing sores, and having an appropriate sore prevention program, including the necessary supplies available to execute the program, are all essential to providing appropriate care to individuals who may not be able to care for themselves.