A bed sore, or pressure sore, is a commonly used term for what doctors call a decubitus ulcer, resulting from prolonged pressure on the skin. The prolonged pressure interferes with blood flow and will eventually cause tissue death. With enough unrelieved pressure, whether continuous or occurring due to episodic pressure without sufficient healing time between episodes, an injury will form that is in many ways similar to a burn. At the mildest level the patient will have reddening of the skin. As the ulcer becomes more serious the patient may display blistering. If not properly treated the ulcer will become an open wound with formation of an eschar, dead skin that blackens and eventually drops off.
Decubitus Ulcers are most often caused by unrelieved pressure to the skin, usually at a location where the skin lies over a bony prominence -- that is, a location on the body where there is not much flesh or muscle between the skin and the underlying bone. Most bed sores occur at the pelvic girdle (the region where the thigh bones connect to the spine), including the sacrum (the lower back beneath the waist) and coccyx (tail bone), the trochanter (upper hip bone), and heel bone, although ulcers may form in other locations such as the elbows. In nursing home settings, particularly with bedridden or wheelchair-bound residents, you may see pressure sores on a resident's ears or head, the back and shoulder blades, the back of a resident's arms or legs where they rest against a wheelchair, or the knees and ankles. Injury to the skin caused by shear, the pulling of skin in the opposite direction of the movement of the body, can make a patient vulnerable to a decubitus ulcer at the point of trauma. Decubitus ulcers can also be caused by friction, such as a point of rubbing between a cast or brace and the flesh beneath it, or from exposure to cold temperatures.
In nursing home settings, ulcers most often form when a resident who has limited mobility remains in one position for an extended period of time, with the resident's body weight imposing pressure on the flesh that rests against a mattress (hence "bed sore") or wheelchair.
A decubitus ulcer has four stages:
The patient's skin is intact, but may appear pink or, on patients with darker skin, discolored. Skin surrounding the pink area does not blanch (whiten) in response to pressure. Pressure may feel painful, and the site of the sore may be warm or cool to the touch as compared to surrounding skin.
The patient's outer layer of skin is no longer intact, and a sore can be observed that may look like a pit or crater. The sore may be shallow and pink or red, or look like a fluid-filled or ruptured blister. There may be signs of infection in the surrounding tissue.
The ulcer has become a deep wound. It is likely to look like a pit or crater. There may be yellow-colored tissue in the wound, dead tissue known as "slough".
The skin is damaged to the point that there is significant tissue loss, and bone or tendon may be visible. Eschar may be present, and the bottom of the sore may show slough or dead tissue.
When the presence of eschar, slough, or dead tissue over the surface of the wound prevents the assessment of the depth of the wound, the ulcer is considered to be unstageable.
A person with a decubitus ulcer can experience a rapid progression from Stage 1 to Stage 3 or 4, with little to no observation of any intermediate stage.
Arguably, residents of nursing homes and medical care facilities should alm ost never develop decubitus ulcers. With a sufficient level of diligence by staff, it should be possible to prevent most residents from developing a pressure sore. Yet the world is a complicated place, and the development of a pressure sore of itself is not proof of negligent or abusive care. Sometimes the primary cause is the resident's refusal to accept proper nutrition and hydration, to cooperate with wound care prevention or to be noncompliant with treatment when a Stage 1 ulcer is detected. However, in most cases the presence of a pressure sore is a sign of some level of neglect.
As a general rule, a patient with limited mobility should be moved at least once every two hours, or more frequently if medically indicated. Patients may also benefit from the use of protective padding, placed at vulnerable locations to minimize pressure and prevent abrasion. Vulnerable patients may benefit from special bedding or pressure relief devices that help keep pressure off of vulnerable areas of their bodies.
Care should be exercised to ensure that residents receive proper nutrition and are properly hydrated. Special care should be exercised with patients who are at high risk of decubitus ulcers, including those with limited mobility, diabetes, vascular disorders, or other medical conditions that can interfere with the flow of blood. Similarly, extra care must be exercised with patients who are not fully aware of their surroundings or are not conscious, due to a medical condition, medication, disease or trauma, and may be partially or wholly unable to take independent action to prevent pressure sores or to inform staff of their symptoms. Other medical conditions such as a loss of sensation in the skin and muscle spasm should also trigger extra vigilance. Older patients and smokers are at higher risk of developing decubitus ulcers.
Patients should not have moisture close to their skin for extended periods, for example as a result of delays in changing adult diapers or cleaning soiled bedsheets.
Residents should be checked on a frequent, regular schedule for the development of decubitus ulcers, so that prompt corrective action may be taken and medical care can be provided if necessary.
Upon detection of a Stage 1 decubitus ulcer, immediate steps should be taken to keep pressure off of the sore. If the sore does not improve within 24 to 48 hours, or if there is any sign of infection, a physician should examine the ulcer. Any wounds should be properly cleaned and dressed. It may be appropriate to provide pain management treatment, or to prescribe antibiotics.
When dead tissue is present, it is necessary to debride the wound (remove the dead tissue). The technique used for debridement will depend on factors including the severity of the wound, treatment goals, and the patient's overall medical condition.
If a pressure sore does not respond to other treatments, it may be necessary to perform surgery. In some cases, a pad of skin may be transplanted from another part of the body to cover the pressure sore.
Family members should be notified of the presence of any ulcers and, when appropriate, educated in proper wound care and prevention. With proper attention and care, a sore should be identified and cured within a two week period.
Serious complications can arise from the improper care and treatment of decubitus ulcers, including:
Cellulitis is an infection of the soft tissues and skin. It can be extremely painful and is potentially life-threatening.
Sepsis occurs when bacteria are introduced to the bloodstream, triggering an autoimmune response that triggers whole-body inflammation. It is an extremely dangerous, rapidly progressing, life-threatening condition.
Infections of Bones and Joints
As a pressure sore becomes a deep wound, it can reach bones, joints and cartilage, creating a risk of serious infection. Infections of this type can be disabling, can reduce limb function, and can be life-threatening.
A form of cancer called squamous cell carcinoma can develop in chronic, non-healing wounds. When this occurs, the patient will almost always require surgery.
With a severe enough ulcer or resulting complications, a patient may suffer the loss of a limb or death. All decubitus ulcers should be regarded as potentially life-threatening, even in their earliest stages.