What are bedsores?

Bedsores — also called pressure ulcers/sores and decubitus ulcers — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.

People most at risk of bedsores are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.

Bedsores can develop VERY quickly. Most sores heal with treatment, but some never heal completely.

 

You can take steps to help prevent bedsores and aid healing.

Symptoms – How would one know if they are developing a pressure sore?

  • Unusual change in skin colour or texture. They start as pink/reddish areas which can turn to dark purple 

  • Swelling

  • A blister which may be intact or may break open

  • Pus-like fluid draining 

  • An area of skin that feels cooler or warmer to the touch than other areas

  • Tender areas. Skin may be intact or may have broken through and feel a little raw.

Bedsores fall into one of several stages (one to four) based on their depth, severity, and other characteristics. The degree of skin and tissue damage ranges from red, unbroken skin to a deep injury involving muscle and bone. Bedsores can become so severe that they can cause systemic infection and even death. Some pressure sores are not able to be staged and may require removal or debridement of dead tissue before the stage can be determined. This is referred to as unstageable.

WARNING: IMAGES MAY BE GRAPHIC

STAGE 1:

This is an early or mild pressure sore. The skin is red and still intact. It may heal in 2 to 3 days if action is taken.

STAGE 2:

The skin breaks open and it looks like a scrape or a blister and is raw and tender. This image is of a shearing injury from constant sliding down in an elevated bed. This can cause further tissue damage and can develop into an ulcer. 

STAGE 3:

The Sore has extended into the second layer of skin into the fat tissue.  It looks like a raw crater and may show signs of infection. Yellow, brown or black areas may cover parts of the wound and this is known as “slough”

STAGE 4:

The Sore is deep, and you may be able to see muscle, tendons and even bone. It is now a very serious wound which may take months or years to heal. Wounds may be wide open or small yet very deep like this photo of a hip pressure sore.

UNSTAGEABLE:

Often the wound is still closed and may look superficial. It however can be very severe. As the bottom of the wound is not visible, it is referred to as unstageable. The doctor may need to open it up and clear away debris before he can determine the Stage and severity of the wound.

UNSTAGEABLE WOUND WITH SUSPECTED DEEP TISSUE DAMAGE:

The image below shows the hip of an Elderly, thin patient who had been lying on her side for prolonged periods. The pressure sore although intact, is severe. Suspected deep tissue injury has occurred.  This is also referred to as Unstageable.

The heels can be especially prone to pressure sores. It is common for one to be discharged from hospital after a few days at bedrest and have painful red heels. These can develop into deep wounds which can be dangerous, particularly for Diabetic patients who may have delayed healing. We have seen patients have amputations due to complications from heel pressure sores.

What are the common sites for 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, elbows, heels, and legs where they rest against the chair or on the bed

 

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

  • Back or sides of the head

  • Ears

  • Shoulder blades and elbows

  • Hips, spine, lower back, or tailbone

  • Heels, ankles, and skin behind the knees

How are Pressure Sores caused?

Bedsores are caused by pressure against the skin that limits blood flow to the skin. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores.

Three primary contributing factors for bedsores are:

  • Pressure. Constant pressure on any part of your body can lessen the blood flow to tissues. Blood flow is essential to delivering oxygen and other nutrients to tissues. Without these essential nutrients, skin and nearby tissues are damaged and might eventually die. For people with limited mobility, this kind of pressure tends to happen in areas that aren't well-padded with muscle or fat and that lie over a bone, such as the spine, tailbone, shoulder blades, hips, heels and elbows.

  • Friction. Friction occurs when the skin rubs against clothing or bedding. It can make fragile skin more vulnerable to injury, especially if the skin is also moist.

  • Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone might stay in place — essentially pulling in the opposite direction

 

Who is at risk of developing a pressure sore?

People are at risk of developing pressure sores, if they have difficulty moving and are unable to easily change position while seated or in bed. Risk factors include: 

 

  • Underweight/very thin or obese patients 

  • Immobility. This might be due to poor health, spinal cord injury and other causes.

  • Lack of sensory perception. Spinal cord injuries, unconscious patients, patients with neurological disorders and other conditions which can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of warning signs and the need to change position.

  • Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.

  • Medical conditions affecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage.

  • End of life patients. Sometimes despite our best efforts to prevent pressure sores in the dying patient, sores still develop. Family members often feel that, as there are only hours or days left, that the nurse should leave their loved one in a comfortable position to avoid pain or discomfort when changing the position or turning, BUT, pressure sores can be painful and unpleasant. These can develop within hours once the circulation to the tissues becomes inadequate.

 

I always try to explain to my own clients, that we must try to imagine lying in one position at night for 8 hours when sleeping without turning. We would wake up feeling very sore and stiff. We turn ourselves between 3 and 36 times per night and turning or changing position can prevent pain and stiffness.

 

What are the Complications of pressure sores? 

 

Complications of pressure ulcers, some life-threatening, include Cellulitis (an infection of the skin and connected soft tissues), Bone and joint infections and sepsis.

 

When should I seek medical attention?

 

If you notice early warning signs of a bedsore, change your position to relieve the pressure on the area. If you do not see improvement in 24 to 48 hours, contact your doctor.

Seek immediate medical care if you show signs of infection, such as a fever, drainage from a sore, a sore that smells bad, or increased redness, warmth or swelling around a sore.

 

Can I prevent a pressure sore?

You can help prevent bedsores by frequently repositioning yourself to avoid stress on the skin. Other strategies include taking good care of your skin, maintaining good nutrition and fluid intake.

Tips for repositioning

Consider the following recommendations related to repositioning in a bed or chair:

  • Shift your weight frequently. If you use a wheelchair, try shifting your weight about every 15 minutes. Ask for help with repositioning about once an hour.

  • Lift yourself, if possible. If you have enough upper body strength, do wheelchair push ups — raising your body off the seat by pushing on the arms of the chair.

  • Look into a specialty wheelchair. Some wheelchairs allow you to tilt them, which can relieve pressure.

  • Select cushions or a mattress that relieves pressure. Use cushions or a special pressure relief mattress to help ensure that your body is well-positioned and that the tissues are well circulated. 

  • Do not use doughnut cushions, as they can focus pressure on surrounding tissue.

  • Use a good quality 100% authentic sheepskin to cushion pressure areas and provide a spongy non slip surface. These also allow aeration and do not promote sweating.

  • Adjust the elevation of your bed. If your bed can be elevated at the head, raise it no more than 30 degrees. This helps prevent shearing.

Consider the following suggestions for skin care:

  • Keep skin clean and dry. Wash the skin with a gentle cleanser and pat dry. Avoid harsh soaps as these can dry the skin too much. Do this cleansing routine regularly to limit the skin's exposure to moisture, urine, and stool.

  • Protect the skin: Use plain talcum powder to protect skin at friction points. 

  • Massage potential pressure areas and areas of dry skin. One can use unscented Aqueous Cream or preferably milking cream at least 3 times per day or more often if necessary

  • Change bedding and clothing frequently if needed. Watch for buttons, labels on clothing, diapers which have folded under the bottom or are too tight in the groin or wrinkles or crumbs in the bedding that irritate the skin.

  • Inspect the skin daily. Look closely at your skin daily for warning signs of a pressure sore.

 

Our Durban North Nursing Sisters, use and recommend the following products:

Barrier and moisture Cream - 3M Cavilon Barrier cream works well particularly in the diaper area, for persons who may be incontinent, protecting the at-risk skin from damage in wet and damp areas. It is durable, resists easy wash off and it does not affect the adherence of tape and dressings.

 

Talcum Powder - Johnsons Antiseptic powder absorbs excess moisture and perspiration keeping skin dry and odour free. Avoid using in the diaper as a barrier cream is all you need in the very wet areas

 

Milking Cream for massage and skin nourishment – Madaji Milking Cream is a non-expensive, wonderfully rich, and nourishing cream containing an antiseptic, Vitamin E and Lanolin. 

 

Soap free body wash product – Elizabeth Anne’s Special Baby Shampoo can be used safely on all skin areas and hair.  It is moisturising, gentle and soap free.

Items that one may purchase or hire which may assist in reducing the risk of developing a pressure sore:

SHEEPSKIN BOOTIES

BUBBLE/RIPPLING ALTERNATING PRESSURE RELIEF MATTRESS 

100% AUTHENTIC MEDICAL SHEEPSKIN