Bed Ulcers, Decubitus Ulcers, Pressure Sores
Bedsores are also known as pressure sores or decubitus ulcers. They form when your bone squeezes your skin and tissue against an outside surface, usually on weight-bearing parts of your body where the bones are near the skin. Bedsores usually develop below your waist if you are bedridden, although they can occur almost anywhere on your body. Common sites are the hips, shoulder blades, elbows, base of the spine, knees, ankles, heels, and even between fingers and toes.
Bedsores can develop in some people with just a few hours of constant pressure and range from mild reddening to severe craters that extend into the muscle and bone. They're quite a nuisance and often painful. Anyone who must remain in a bed, chair, or wheelchair for extended periods can develop these sores.
Most pressure sores affect patients over 70 years old who are bedridden in hospitals and long-term care facilities. In Canada, about 25% of people in acute-care settings (e.g., hospitals) develop pressure sores. In non-acute care settings (e.g., nursing homes), the prevalence of pressure sores is even higher (about 30%).
Bedsores are injuries caused by constant and unrelieved pressure that damages the skin and underlying tissue due to lack of mobility and blood circulation (i.e., being bedridden). If you must sit or lie for prolonged periods, the surface of your seat or bed puts excessive pressure on the bony prominences or pressure points in your body. Common pressure points on the body include the tail bone (sacrum), hip bone areas, and the ankle and heel. Less common sites include the elbows, spine, ribs, and back of the head.
Pressure sores may also result from friction caused by your skin rubbing against another surface, or when two layers of skin slide on each other, moving in opposite directions and causing damage to the underlying tissue. This may happen if you are transferred from a bed to a stretcher, or if you slide down in a chair.
Excessive moisture that softens your skin and reduces its resistance can also cause pressure sores. This can occur with excessive perspiration and with urinary or fecal incontinence.
All the factors listed below place you at higher risk for pressure sores:
- fecal or urinary incontinence
- poor nutrition
- decreased level of consciousness
- low body weight
- corticosteroid use
Medical conditions such as the following also put you at risk:
- diabetes mellitus
- cancer malignancies
Symptoms and Complications
A pressure sore usually begins as a reddened, sensitive patch of skin and then goes on to develop into a sore or ulcer that can extend deep into the muscle and even bone. If left untreated, a pressure sore may lead to cellulitis or a chronic infection.
Making the Diagnosis
If you're bedridden or in a wheelchair, your doctor or nurse should be watching for signs of bedsores. Their appearance and predictable locations on the body make them easy to diagnose. The severity of your skin breakdown may be categorized as follows:
- stage 1: Abnormal redness of the skin, with skin intact. This stage is reversible.
- stage 2: The redness progresses to an abrasion, blister, or shallow crater. This stage is also reversible.
- stage 3: A crater-like sore or ulcer that has begun to extend beneath the skin. This stage may be life-threatening.
- stage 4: Skin loss with extensive destruction or damage to muscle, bone, or supporting structures such as tendons or joint capsules. This stage may be fatal.
Treatment and Prevention
The best way to prevent bedsores is by moving around frequently to avoid constant pressure against your body and to redistribute your body weight and promote blood flow to the tissues. If you can't move, you should be helped to reposition at least every 2 hours or every 15 minutes if you are seated in a chair. Pillows or foam wedges can help shift your weight if you're unable to move. Range-of-motion exercises can help prevent contractures; improve circulation; and maintain joint integrity, mobility, and muscle mass.
Your bed should not be elevated more than 30 degrees (except when you're eating) to reduce shearing forces. For the same reason, a pull-sheet should be used to help repositioning in bed.
A convoluted "egg-crate" foam pad is an inexpensive and lightweight solution for some people. This high-density, solid, 5 cm to 10 cm foam pad is less likely to be compressed by your body weight and may help redistribute body weight effectively. Unfortunately, these pads provide only minimal pressure relief and may cause retention of body heat, thereby increasing perspiration. They're useful if your activity is limited to a short time. Alternating pressure mattresses and water mattresses may also help.
Although sheepskin is not thick or dense enough to reduce pressure, some people find it useful if they are predisposed to skin breakdown from friction. For example, a sheepskin at the foot of your bed may decrease friction against your heels if you have vascular disease.
Splints can also be used and should be placed at pressure points. In addition, special anatomically shaped cushions help to distribute your weight more evenly and keep pressure from building in one spot. Heels and elbows may require specially designed pads. Some medical supply stores carry bed cradles that raise the weight of covers off your body and create a tent-like structure.
Your skin should be inspected and cleaned regularly. Keeping it dry and clean helps prevent infection and potential sores from developing. Affected skin should be gently washed with plain water or a small amount of mild soap and water, applying minimal force and friction. Soap removes the skin's natural protective oils, and the cleaning action may irritate already damaged tissues. Next, a thin layer of moisturizing lotion should be applied, massaging gently around, rather than over, the reddened area or bony prominence. Vigorous massage may increase tissue damage by creating shearing forces. After moisturizing the area, a thin layer of a petroleum-based product should be applied. These water-resistant products provide a protective barrier. Heavier agents such as zinc oxide and aluminum paste aren't recommended, because although they are protective, they are also difficult to remove.
Use caution with absorbent incontinence briefs, indwelling bladder catheters, or condom catheters. Although helpful, these devices shouldn't be substituted for efforts to help regain continence through bowel and bladder management programs.
A nurse or doctor should treat bedsores. Healing may take a long time, and thus prevention is the preferred approach.
The treatment of bedsores depends on the severity (i.e., the stage) of the wound to the skin. Depending on the severity, a variety of approaches may be used to promote healing. They include synthetic dressings, saline dressings, acetic acid compresses, and various antibiotic dressings (bedsores are particularly prone to infection). For more severe wounds, surgery may be necessary to remove areas of dead skin. The most important step in both treating and preventing bedsores is relieving pressure by frequent repositioning.