Pressure Sores (Bedsores)

Immobile patients can develop bedsores.

• Pressure sores are areas where unrelieved pressure over a defined area results in local ischemia and eventually can lead to deep tissue damage and necrosis. The affected areas of skin usually cover a bony prominence (for example, skin over the hips, sacrum, or heels).
• The main cause of pressure sores is immobility of the patient; other contributing factors or causes are friction and/or shear forces, inability to feel pain, incontinence, thin skin, poor nutrition, and infections.
• The main risk factor for pressure sores is immobility, especially immobility of the hips and/or buttocks, although other areas of the body may be affected.
• The signs and symptoms of pressure sores vary with the progressive stages the pressure sore may develop; stages range from I-IV, and symptoms in the usual order of appearance (although there may be overlapping of signs and symptoms) are as follows:
  • Discolored skin (purple or dark red)
  • Blisters that may be blood-filled
  • Skin that blanches (turns white) when pressed with the finger
  • Swelling and/or warmth of the skin
  • Partial thickness of skin lost
  • Skin is painful and tender to touch
  • Beginning of ulcer development
  • Full-thickness loss of skin, but fascia remains intact
  • Deeper ulcers
  • In stage III and IV, some people may not feel pain due to extensive destruction of tissue.
  • Full-thickness tissue loss along with extension to the muscle, bone, tendon, or joint
  • Pus production
• Although primary-care doctors treat some types of pressure sores, specialists in emergency medicine, critical care, hospitalists, geriatricians, urologists, plastic surgeons, internists, and nutritional experts may need to be consulted.
• Physicians assess and diagnose pressure sores by clinical observation and usually can assign a stage (I-IV); other tests include laboratory studies of the blood, bone scans, X-rays, MRIs, and/or bone biopsies to more accurately stage pressure sores.
• The majority of pressure sores are stage I or II. Many can be healed by themselves if pressure is reduced or eliminated and treatment, if any, consists of topical skin care.
• More serious pressure sores may require treatment with tissue debridement, wound care, antibiotics, cleaning agents, barrier creams, and even platelet-derived growth factors for skin regeneration. Patients may require concomitant treatment of an underlying problem such as diabetes, poor nutrition, anemia, fecal and/or urine incontinence, and/or surgical interventions.
• Home remedies for pressure sores may include purchase of a special mattress, relatives or caregivers trained to rotate and/or mobilize the patient, good wound care at home, and the patient participating by stop smoking and following dietary recommendations.
• Complications of pressure sores can be numerous (for example, anemia, fistula formation, osteomyelitis, infectious arthritis, renal failure, and others).
• The prognosis for pressure sores is usually good if the sores are treated early in the disease process; if serious complications develop, the prognosis declines to fair or even poor.
• Pressure sores can be prevented mainly by avoiding any long-term or constant pressure on any body part by encouraging mobility of the patient if possible; other measures -- such as avoiding shear forces on the skin, good skin care, and treatment of underlying diseases or conditions such as diabetes, anemia, and poor nutrition -- can reduce the chances of pressure sores developing.

Pressure sores (also termed bedsores, pressure ulcers, decubitus ulcers, ulcers of heel, hip, tailbone, or midfoot) is a term that describes an area that has unrelieved pressure over a defined area of the skin that is usually covers a bony prominence like the hip, sacrum, or heels, that results in local ischemia (poor or inadequate blood flow), and can progress to local skin cell death and eventually deep tissue necrosis. Although the term bedsores is utilized frequently, especially in the lay press, pressure sores is a broad term that includes pressure problems that can originate from other conditions than just the hospital or home bed.

The main cause of a pressure sore is impaired mobility of the patient. If the patient is not moving, areas of skin that cover bony prominences such as the hips, buttocks, back, and extremities may be subjected to constant pressure that causes skin breakdown because of the pressure-induced ischemia (low blood flow to the pressure damaged tissues). However, there are other causes that affect the patient that contribute to the formation of pressure sores. Some of the major contributors toward the development of pressure sores are as follows:

• Impaired mobility due to sedation, anesthesia, neurologic problems or trauma
• Friction and shear forces: pulling sheets or covers against damaged skin, skin rubbing against itself
• Inability to feel pain: anesthesia, neurologic damage
• Incontinence of urine or feces: Moisture causes maceration of skin.
• Skin condition of the elderly: Thin skin in the elderly is easily susceptible to pressure sores.
• Poor nutritional status: Anemia and/or malnutrition can result in skin damage.
• Bacteria may colonize and/or infect damaged or macerated skin.

It is not unusual for a patient with pressure sores to have more than one of the above conditions.

The main risk factor for pressure sores to develop is immobility. Patients who are confined to the bed (for example, are comatose or paralyzed) or confined to a wheelchair and have difficulty or cannot move their bodies are at high risk for developing pressure sores. Other risk factors are described above. The areas at highest risk for developing pressure sores are the hips and buttocks (70%).

The risk areas are as follows:

• Hips
• Buttocks
• Sacrum and coccyx (tailbone)
• Spine
• Heels
• Shoulders
• Ankles
• Back of head
• Between the knees (legs rubbing together)

Some patients develop multiple areas where pressure sores develop. The more immobile patient is, the more likely the patient will be at high risk for developing pressure sores. Other risk factors for pressure sores include smoking cigarettes, diabetes, high fevers and lack of mobility after hip surgery.

The signs and symptoms of pressure sores vary with the stage or condition of skin and muscle at the body site. Pressure sores are staged according to their development and the signs and symptoms vary with the stage. Consequently, the signs and symptoms depend upon the stage of development of the pressure sores. Depending upon what experts are quoted, pressure sores can be categorized into about four or six stages, but no matter which experts describe stages, they all agree it can be a progressively serious problem.

This article presents the stages of pressure sores according to the National Pressure Ulcer Advisory Panel (NPUAP) that lists six categories but only four stages. The symptoms and signs of all six categories will be presented.

• Suspected deep tissue injury: Discolored skin (purple or dark red) is intact or may have blood-filled blisters; there are no breaks or tears in the skin, but patients may experience some pain.
• Stage I: Intact discolored skin that still may blanch (skin turns white when pressed with finger); erythema; area may be chronically swollen and warmer than surrounding skin
• Stage II: There is partial-thickness loss of skin, including the epidermis and some of the dermis; skin is painful, tender to touch, and ulcers may begin to develop.
• Stage III: There is full-thickness loss of skin, including some of the subcutaneous tissue but not through the underlying fascia; ulcers may be deep but do not show muscle or bone. Some patients in stage III and stage IV may not feel pain due to extensive tissue destruction.
• Stage IV: There is full-thickness tissue loss with extension to the muscle, bone, tendon or joint, often with pus production that can be colored (yellow, gray, green, brown, or black).
• Unstageable: There is full-thickness tissue loss with the base covered by sloughed tissue, pus, or eschar, where the full depth of the wound (pressure ulcer) is initially undetermined.

In some individuals, because these pressure sores advance in severity over time, signs and symptoms may overlap.

Although the patient's primary-care doctor can treat some of the types pressure sores, it is not unusual for some specialists to be consulted. Such specialists may include emergency-medicine and critical-care physicians, hospitalists, geriatricians, neurologists, and even general surgeons or plastic surgeons. Because many of these patients with pressure sores have other underlying problems, specialists like nutritionists and internal-medicine doctors who treat diabetes, and its complications, are often involved in caring for patients with pressure sores.

Physicians assess pressure sores by the patient's history and physical exam. In most patients, the diagnosis is made clinically and is categorized or staged as described above. However, laboratory studies determine the extent of the problem and some of its underlying contributing problems. For example, nutritional parameters can be determined by looking at tests that determine serum protein levels transferrin levels, albumin levels, and others like the WBC count, blood cultures, and ESR (erythrocyte sedimentation rate) tests may identify signs of anemia, sepsis, and/or osteomyelitis. Other tests such as bone scans, X-rays, MRIs, and/or bone biopsies may be utilized to help stage pressure sores.

Although about 70%-90% of pressure sores are stage I or II, immediate treatment usually can avoid any surgical intervention and may allow pressure sores to heal by themselves (secondary intention) if pressure is reduced or eliminated, and treatment, if any, involves superficial or topical skin care.

Key principles in treatment of all types of pressure sores involves the following:

• Reduction of pressure (appropriate mattresses, increased mobility or carefully moving bedridden patients regularly, for example)
• Adequate debridement of necrotic (dead or dying) tissue (surgical removal of necrotic tissue and repeated and careful wound care
• Infection control (antibiotics, when appropriate)
• Careful, regular wound care (regular dressing changes, negative pressure wound therapy, cleaning agents, barrier creams, moisturizing creams and/or topical antimicrobials, if appropriate)
• Some patients may benefit from use of becaplermin (Regranex), a gel-containing platelet derived growth factors for treatment of diabetic skin ulcers.

Treating the underlying problems, such as diabetes, poor nutrition, correction of anemia, and/or management of fecal or urine incontinence that may play a significant development of pressure sores and/or surgical intervention (skin grafts or flaps, muscle flaps, release of flexion contractures, amputation), may be necessary in some patients.

In general, pressure sores (especially types II to IV) are best cared for by the patient's doctors. However, some home remedies can help most types of pressure sores to have a better chance to heal. For example, purchase of a good mattress, relatives or family members who are trained to rotate and/or mobilize the patient at home, and following the directions for treatment of underlying causes (such as diabetes) will help. Family and friends can also help by performing good wound care at home and by administering appropriate barrier creams and other agents that preserve skin after pressure sores heal. In addition, if the patient can cease smoking and follow the recommendations for a high-protein diet, they may reduce the chance of recurrent pressure sores.

Pressure sores, if treated early (stage I), have few if any complications. However, complications become more likely as the disease progresses. Complications can include the following:

• Anemia
• Fistula formation (urethral, fecal)
• Osteomyelitis
• Pyarthrosis (infectious arthritis)
• Altered cells may become malignant
• Autonomic dysreflexia (sudden onset of high blood pressure)
• Renal failure
• Amyloidosis (progressive deposition of amyloid in organs)
• Bacteremia
• Sepsis
• Coma/death

The prognosis or outcomes of pressure sores is usually good if they are treated early the disease process. Complications can develop as the disease progresses, and stages III, IV, and "undetermined" may have a prognosis that ranges from fair to poor, depending upon the location of the pressure sore(s) and the patient's response to treatments. Patients with paraplegia have a death rate of about 7%-8% due to pressure sores.

Yes, pressure sores can be prevented. Prevention can start either at home or in the hospital setting by making sure to avoid long-term or constant pressure on any part of the patient's body. This can be done in part by encouraging mobility, by moving or rotating an immobile patient regularly (determined by the patient's physician), avoiding shear forces on skin made by pulling on sheets or by pulling the patient across sheets, and by avoiding situations that lead to damaged skin (patient laying in urine or feces for extended time periods). Good skin care with moisturizers and/or other creams may also help prevent pressure sores. Treatment of underlying causes, such as diabetes, anemia, and poor nutrition, can also help prevent skin breakdown and pressure sores. In addition, ceasing cigarette smoking may reduce the risk of developing pressure sores.