Bedsores (pressure sores)

Definition:

Bedsores — also called pressure sores or pressure ulcers — are injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks.

People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for prolonged periods.
Bedsores can develop quickly and are often difficult to treat. Several care strategies can help prevent some bedsores and promote healing

Symptoms:

Bedsores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization that promotes the prevention and treatment of pressure ulcers, has defined each stage as follows.
Stage I
The beginning stage of a pressure sore has the following characteristics:

• The skin is intact.
• The skin appears red on people with lighter skin color, and the skin doesn't briefly lighten (blanch) when touched.
• On people with darker skin, there may be no change in the color of the skin, and the skin doesn't blanch when touched. Or the skin may appear ashen, bluish or purple.
• The site may be painful, firm, soft, warmer or cooler compared with the surrounding skin.

Stage II
The stage II ulcer is an open wound:

• The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost.
• The pressure ulcer may appear as a shallow, pinkish-red, basin-like wound.
• It may also appear as an intact or ruptured fluid-filled blister.

Stage III
At this stage, the ulcer is a deep wound:

• The loss of skin usually exposes some amount of fat.
• The ulcer has a crater-like appearance.
• The bottom of the wound may have some yellowish dead tissue (slough).
• The damage may extend beyond the primary wound below layers of healthy skin.

Stage IV
A stage IV ulcer exhibits large-scale loss of tissue:

• The wound may expose muscle, bone and tendons.
• The bottom of the wound likely contains slough or dark, crusty dead tissue (eschar).
• The damage often extends beyond the primary wound below layers of healthy skin.

Common sites of pressure sores
For people who use a wheelchair, pressure sores often occur on skin over the following sites:

• Tailbone or buttocks
• Shoulder blades and spine
• Backs of arms and legs where they rest against the chair

For people who are confined to a bed, common sites include the following:

• Back or sides of the head
• Rim of the ears
• Shoulders or shoulder blades
• Hip, lower back or tailbone
• Heels, ankles and skin behind the knees

When to see a doctor
Inspection of the skin should be a part of routine nursing or home care for anyone who is confined for a long time to a wheelchair or bed or for anyone who has limited ability to reposition himself or herself. Contact your doctor right away if you notice any signs or symptoms of a pressure ulcer. Get immediate medical care if a person under your care shows signs of infection, such as fever, drainage or foul odor from a sore, or increased heat and redness in the surrounding skin.

Causes:

Pressure sores are caused by pressure against the skin that inhibits an adequate supply of blood to skin and underlying tissues. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores. There are three primary contributing factors:

• Sustained pressure. When your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, the pressure may be greater than the pressure of the blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to tissues. Deprived of these essential nutrients, cells of the skin and other tissues are damaged and may eventually die. This kind of pressure tends to happen in areas that aren't well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows.
• Friction. Friction is the resistance to motion. When a person changes position or is handled by care providers, friction may occur when the skin is dragged across a surface. The resistance to motion may be even greater if the skin is moist. Friction between skin and another surface may make fragile skin more vulnerable to injury.
• Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a hospital bed is elevated at the head, a person can slide down in bed. As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction. This motion may damage tissue and blood vessels, making the site more vulnerable to damage from sustained pressure.

Complications:

Complications of pressure ulcers include:

• Sepsis. Sepsis occurs when bacteria enters your bloodstream through the broken skin and spreads throughout your body — a rapidly progressing, life-threatening condition that can cause organ failure.
• Cellulitis. This acute infection of your skin's connective tissue causes pain, redness and swelling, all of which can be severe. Cellulitis can also lead to life-threatening complications, including sepsis and meningitis — an infection of the membrane and fluid surrounding your brain and spinal cord.
• Bone and joint infections. These develop when the infection from a pressure sore burrows deep into your joints and bones. Joint infections (septic or infectious arthritis) can damage cartilage and tissue, and bone infections (osteomyelitis) may reduce the function of your joints and limbs.
• Cancer. Another complication is the development of a type of squamous cell carcinoma that develops in chronic, nonhealing wounds (Marjolin ulcer). This type of cancer is aggressive and usually requires surgical treatment.

Treatments and drugs:

Stage I and stage II pressure sores usually heal within several weeks to months with conservative care of the wound and with ongoing, appropriate general care that manages risk factors for pressure sores. Stage III and IV pressure sores are more difficult to treat. In a person who has a terminal illness or multiple chronic medical conditions, pressure sore treatment may focus primarily on managing pain rather than complete healing of a wound.

Treatment team
Addressing the many aspects of wound care usually requires a multidisciplinary approach. Members of a care team may include:

• A primary care physician who oversees the treatment plan
• A physician specializing in wound care
• Nurses or medical assistants who provide both care and education for managing wounds
• A social worker who helps a person or family access appropriate resources and addresses emotional concerns related to long-term recovery
• A physical therapist who helps with improving mobility
• A dietitian who assesses nutritional needs and recommends an appropriate diet
• A neurosurgeon, orthopedic surgeon or plastic surgeon, depending on whether surgery is required and what type of surgery is needed

Relieving pressure
The first step in treating a sore at any stage is relieving the pressure that caused it. Strategies to reduce pressure include the following:

• Repositioning. A person with pressure sores needs to be repositioned regularly and placed in correct positions. People using a wheelchair should change position as much as possible on their own every 15 minutes and should have assistance with changes in position every hour. People confined to a bed should change positions every two hours. Lifting devices are often used to avoid friction during repositioning.
• Support surfaces. Special cushions, pads, mattresses and beds can help a person lie in an appropriate position, relieve pressure on an existing sore and protect vulnerable skin from damage. A variety of foam, air-filled or water-filled devices provide cushion for those sitting in wheelchairs. The type of devices used will depend on a person's condition, body type and mobility.

Removing damaged tissue
To heal properly, wounds need to be free of damaged, dead or infected tissue. Removing these tissues (debridement) is accomplished with a number of methods, depending on the severity of the wound, your overall condition and the treatment goals. Options include:

• Surgical debridement involves cutting away dead tissues.
• Mechanical debridement uses one of a number of methods to loosen and remove wound debris, such as a pressurized irrigation device, a whirlpool water bath or specialized dressings.
• Autolytic debridement, the body's natural process of recruiting enzymes to break down dead tissue, can be enhanced with an appropriate dressing that keeps the wound moist and clean.
• Enzymatic debridement is the use of chemical enzymes and appropriate dressings to break down dead tissues.

Cleaning and dressing wounds
Care that promotes healing of the wound includes the following:

• Cleaning. It's essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores are cleaned with a saltwater (saline) solution each time the dressing is changed.
• Dressings. A dressing promotes healing by keeping a wound moist, creating a barrier against infection and keeping the surrounding skin dry. A variety of dressings are available, including films, gauzes, gels, foams and various treated coverings. A combination of dressings may be used. Your doctor selects an appropriate dressing based on a number of factors, such as the size and severity of the wound, the amount of discharge, and the ease of application and removal.

Other interventions
Other interventions that may be used are:

• Pain management. Interventions that may reduce pain include the use of nonsteroidal anti-inflammatory drugs — such as ibuprofen (Motrin, Advil, others) and naproxen (Aleve, others) — particularly before and after repositioning, debridement procedures and dressing changes. Topical pain medications, such as a combination of lidocaine and prilocaine, also may be used during debridement and dressing changes.
• Antibiotics. Pressure sores that are infected and don't respond to other interventions may be treated with topical or oral antibiotics.
• Healthy diet. Appropriate nutrition and hydration promote wound healing. Your doctor may recommend an increase in calories and fluids, a high protein diet, and an increase in foods rich in vitamins and minerals. Your doctor may also prescribe dietary supplements, such as vitamin C and zinc.
• Muscle spasm relief. Muscle relaxants — such as diazepam (Valium), tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen — may inhibit muscle spasms and enable the healing of sores that may have been caused or worsened by spasm-related friction or shearing.

Surgical repair
Pressure sores that fail to heal may require surgical intervention. The goals of surgery include improving the hygiene and appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of cancer.

The type of reconstruction that's best in any particular case depends mainly on the location of the wound and whether there's scar tissue from a previous operation. In general, though, most pressure wounds are repaired using a pad of the person's own muscle, skin or other tissue to cover the wound and cushion the affected bone (flap reconstruction).