Bedsores (Decubitus Ulcers)

What Are They?

Bedsores, also called pressure ulcers or decubitus ulcers, are areas of broken skin that can develop in people who:

• Have been confined to bed for extended periods of time
• Are unable to move for short periods of time, especially if they are thin or have blood vessel disease or neurological diseases
• Use a wheelchair or bedside chair (a hospital chair that allows a patient to sit upright next to the bed)

Bedsores are common in people in hospitals and nursing homes and in people being cared for at home. In the United States, approximately 9% of all hospitalized patients develop bedsores. Three percent to 14% of people in home care get them and so do 3% to 12% of all nursing home residents. People transferred from hospitals to nursing homes are particularly vulnerable, with 10% to 35% having sores when they are admitted to the nursing home.

Bedsores can lead to severe medical complications, include bone and blood infections, infectious arthritis, holes below the wound that burrow into bone or deeper tissues, and scar carcinoma, a form of cancer that develops in scar tissue.

Bedsores form where the weight of the person's body presses the skin against the firm surface of the bed. In people confined to bed, bedsores are most common over the hip, spine, lower back, shoulder blades, elbows and heels. In people who use a wheelchair, bedsores are most common on the lower back, buttocks and legs. This pressure temporarily cuts off the skin's blood supply. This injures skin cells and can cause them to die. Unless the pressure is relieved and blood flows to the skin again, the skin soon begins to show signs of injury. At first, there may be only a patch of redness. If this red patch is not protected from additional pressure, the redness can form blisters or open sores (ulcers). In severe cases, damage may extend through the skin and create a deep crater that exposes muscle or bone.

Muscle is even more prone to severe injury from pressure than skin. A mild injury to the skin may cover a deeper, more pronounced injury to muscle.

The pressure that causes bedsores does not have to be very intense. Pressure of less than 25% the pressure of a normal mattress can lead to bedsores. Normally, our skin is protected from being injured by this pressure because we move frequently, even when asleep.

Although pressure on the skin is the main cause of bedsores, other factors often contribute to the problem. These include:

• Shearing and friction Shearing and friction causes skin to stretch and blood vessels to kink, which can impair blood circulation in the skin. In a person confined to bed, shearing and friction can occur when the person is dragged or slid across the bed sheets. This can also occur when the head of the bed is raised more than 30 degrees. This increases shearing forces over the lower back and tailbone.
• Moisture Wetness from perspiration, urine or feces can make the skin too soft and more likely to be injured by pressure. For this reason, people who can't control their bladders or bowels (incontinent) are at high risk of developing bedsores.
• Decreased movement Bedsores are common in people who can't move because they are paralyzed, recuperating from surgery for a prolonged time, being treated in intensive care for a long time, or are incapacitated by severe arthritis, stroke or a neurological problem such as multiple sclerosis. (People who can move without assistance have a lower risk of bedsores because they can shift their weight periodically.)
• Decreased sensation Bedsores are common in people who have spinal cord injuries or other neurological problems that decrease their ability to feel pain or discomfort. Without these feelings, the person cannot feel the effects of prolonged pressure on the skin.
• Circulatory problems People with atherosclerosis, circulatory problems from long-term diabetes or localized swelling (edema) may be more likely to develop bedsores. This is because the blood flow in their skin is weak even before pressure is applied to the skin. People with anemia are also at risk because their blood cannot carry enough oxygen to skin cells, even though circulation may be normal.
• Poor nutrition Studies show that bedsores are more likely to develop in people who don't get enough protein, vitamin C, vitamin E, calcium or zinc.
• Age Elderly people, especially those over 85, are more likely to develop bedsores because skin usually becomes thinner with age. Also, as we age, fat tends to shift away from the body surface, where it acts as a cushion, to deeper areas of the body.

Symptoms

Sometimes bedsores are classified into stages, depending on the severity of skin damage:

• Stage I (earliest signs of skin damage) White people or people with pale skin develop a lasting patch of red skin that does not turn white when you press it with your finger. In people with darker skin, the patch may be red, purple or blue and may be more difficult to detect. The skin may be tender or itchy, and may feel warm or cold and firm.
• Stage II The injured skin blisters or develops an open sore or abrasion that does not extend through the full thickness of the skin. There may be a surrounding area of red or purple discoloration, mild swelling and some oozing.
• Stage III The ulcer becomes a crater and that goes below the skin surface.
• Stage IV The crater deepens and reaches into a muscle, bone, tendon or joint.

Because broken skin is a prime spot for bacteria, bedsores are extremely vulnerable to infection. This is especially true if the sore is contaminated by urine or feces Signs of infection in a bedsore can include:

• Pus draining from the sore
• A foul smelling odor
• Tenderness, heat and increased redness in the surrounding skin
• Fever

Diagnosis

In most cases, a doctor or nurse can diagnose a bedsore simply by examining the skin. Testing is usually unnecessary unless there are symptoms of infection.

If a person with bedsores develops an infection, a doctor may order tests to find out if the infection has moved into the soft tissues, bones, bloodstream or to another site. Tests may include blood tests, a laboratory examination of tissue or secretions from the bedsore, and radiological tests to look for evidence of a bone infection called osteomyelitis. If you care for a family member who is confined to a bed or wheelchair, your doctor or home care nurse can teach you how to identify the earliest signs of bedsores. You'll learn which areas of skin are particularly vulnerable and what to look for. Once you know how to recognize the earliest signs of skin damage, you can take steps to prevent areas of redness from becoming full-blown ulcers.

Expected Duration

Many factors influence how long a bedsore lasts, including the severity of the sore and the type of treatment, as well as the person's age, overall health, nutrition and ability to move. For example, there is a good chance that a Stage II bedsore will heal within one to six weeks in a relatively healthy older person who eats well and is able to move. Stage II and stage IV ulcers may take six weeks to three months to heal. Often, they can last longer. Thirty percent of stage II ulcers, 50% of stage III ulcers, and 70% of stage IV ulcers take longer than six months to heal.

Bedsores can be an ongoing problem in chronically ill people who have multiple risk factors, such as incontinence, the inability to move and circulatory problems. For this group, the fight against bedsores is often a long-term battle.

Prevention

Health care experts believe that at least 50% of bedsores can be prevented by using simple measures to relieve pressure and decrease the skin's vulnerability to injury. To help prevent bedsores in a person who is confined to a bed or chair, a health care professional should create a plan of care. The plan may include these strategies:

• Relieve pressure on vulnerable areas Change the person's position every two hours when in bed and every hour when sitting in a chair. Use pillows to raise the person's arms, legs, buttocks and hips. Relieve pressure on the back with an egg-crate foam mattress, a water mattress or a sheepskin. Two types of beds air-fluidized beds and low-air-loss beds have been shown to reduce pressure ulcers by up to two thirds.
• Reduce shear and friction Avoid dragging the person across the bed sheets. Either lift the person or have the person use an overhead trapeze to briefly raise his or her body. Keep the bed free from crumbs and other particles that can rub and irritate the skin. Do not raise the head of the bed more than 30 degrees, unless your doctor tells you otherwise. Use sheepskin boots and elbow pads to reduce friction on heels and elbows. Wash the person gently. Avoid rubbing or scrubbing the skin.
• Inspect the person's skin at least once each day Early detection can prevent stage I redness from becoming worse.
• Minimize irritation from chemicals Avoid irritating antiseptics, hydrogen peroxide, povidone iodine solution or other harsh chemicals to clean or disinfect the skin.
• Encourage the person to eat well The diet should include enough calories, protein, calcium, and zinc and vitamins C and E. If the person cannot eat enough food, ask your doctor about nutritional supplements.
• Encourage daily exercise Exercise increases blood flow and speeds healing. In many cases, even bedridden people can do stretches and simple exercises.
• Keep the skin clean and dry Clean the skin with saline (a non-irritating salt solution) rather than harsh soaps. Use absorbent pads to draw moisture away from vulnerable areas. If the person is incontinent, ask your doctor about ways to control or limit the leakage of urine or feces.

Treatment

If you care for someone with bedsores, your doctor or home care nurse may ask you to help with the treatment by following preventive steps that should stop further damage to vulnerable skin and increase the chances of healing.

Additional treatments, usually done by health care professionals, depend on the stage of the bedsore. First, areas of unbroken skin near the bedsore are covered with a protective film or a lubricant to protect them from injury. Next, special dressings are applied to the injured area to promote healing or to help remove small areas of dead tissue. If necessary, larger areas of dead tissue may be trimmed away surgically or dissolved with a special medication. Deep craters may need skin grafting and other forms of reconstructive surgery.

If the person's skin does not begin to heal within a few days after treatment starts, the doctor may prescribe antibiotics, which may be applied as an ointment, taken as a pill or given intravenously (into a vein). Antibiotics also are used to treat bedsores that show obvious signs of infection.

When To Call A Professional

If you find a suspicious area of redness or blistering on a person you are caring for, call a doctor promptly or discuss the problem with your home care nurse.

Prognosis

In many cases, the outlook for bedsores is good. Simple bedside treatments can heal most stage II bedsores within a few weeks. If conservative methods fail to heal a stage III or stage IV bedsore, reconstructive surgery often can repair the damaged area.

Additional Info

National Institute of Arthritis and Musculoskeletal and Skin Diseases

Information Clearinghouse

National Insitutes of Health

1 AMS Circle

Bethesda, MD 20892-3675

Phone: 301-495-4484

Toll-Free: 1-877-226-4267

Fax: 301-718-6366

TTY: 301-565-2966

Email: niamsinfo@mail.nih.gov

http://www.niams.nih.gov/

National Institute on Aging

Building 31, Room 5C27

31 Center Drive, MSC 2292

Bethesda, MD 20892

Toll-Free: 1-800-222-2225

http://www.nih.gov/nia/

American Academy of Dermatology

P.O. Box 4014

Schaumburg, IL 60168-4014

Phone: 847-330-0230

Toll-Free: 1-888-462-3376

Fax: 847-330-0050

http://www.aad.org/