Bedsores

Alternative names

pressure sores; pressure ulcers; decubitus ulcers

Definition

Bedsores are ulcers of the skin caused by unrelieved pressure. This condition can result from lying or sitting in one position for too long, such as when a person is bedridden or confined to a wheelchair.

In most cases, a person is relatively immobile as a result of another illness or condition. Bedsores are considered to be an aside to their primary medical problem.

However, these ulcers can cause significant pain and discomfort. They can be serious, depending on how much of the skin and tissue becomes damaged. A bedsore can extend into the muscle and fat and even the bone tissue beneath it. It can also become infected and this infection may spread to other parts of the body.

Causes

Bedsores are usually caused by sitting or lying in one position for too long without a change. This puts pressure on certain areas of the body and can reduce the blood supply to the skin and the tissues beneath, depriving the skin cells of oxygen. When blood supply to the skin is cut off for more than two to three hours, the skin cells begin to die and a bedsore starts to develop. Left untreated, the skin can break open and become infected.

Bedsores usually develop over bony parts of the body that don't have much fat to pad them, and/or which bear a lot of weight. They are most common on the heels and hips and buttocks. Other areas at risk for bedsores include the base of the spine, the shoulder blades, the backs and sides of the knees, and the back of the head.

As well as pressure, ulcers can sometimes form from friction and irritation from poorly adjusted supports or wrinkled bedding, and from shearing. Shearing forces occur when the skin moves one way, while the underlying bone moves another. This can occur, for example, when sitting up in bed with the back of the bed raised. You tend to slide down the bed, causing your bones to move while your skin stays still. Friction injuries or abrasions may also occur through poor transfer techniques (when moving an immobilised person), falls or muscle spasm. Frequent leg spasms in bed, for example, may cause blisters to develop on the heels from repeated rubbing against the sheets.

Who gets it and who is at risk?

Anyone who sits or lies in one position for a long time might get bedsores. You are more likely to get bedsores if you use a wheelchair or are bedridden. However, people who are able to walk can get bedsores when they stay in bed because of an illness or injury or wear a cast for a prolonged period of time.

Conditions or circumstances that may increase the risk of developing bedsores include:

• Loss of pain and pressure sensations, for example from a spinal injury. A person with such a condition may be unaware they are developing bedsores.
• Spasticity, which can cause repetitive pressure or friction to an area of the body.
• Loss of adequate blood flow in a paralysed extremity.
• Trauma (injury) and softening of the skin
• Moisture from perspiration, urinary incontinence or faecal incontinence.
• Disuse atrophy: fat and muscle tissue wastes away, so there is less padding between bony and weight-bearing parts of the body and the skin.
• Infection
• Malnutrition
• Anaemia (red blood cell deficiency)

Symptoms and signs

Bedsores are characterised as follows:

Signs that the bedsore is infected:

Signs that the infection may have spread include the following:

• Early, mild damage causes the skin to be discoloured but a sore doesn't form. In light-skinned people, the damaged skin may turn red, and later purple. In dark-skinned people, the area may become darker than normal. The area of damaged skin may also feel warmer than the surrounding skin.
• In later stages, the bedsore may blister and open.
• The tissue may become necrotic (the cells die) through the skin into the fat and muscle, and finally necrosis can even extend through the tissue into the bone.
• Bedsores are painful and make it hard for a person to move around.
• Bedsores that become infected heal more slowly and can spread a dangerous infection to the rest of your body.
  • Thick yellow or green pus
  • A bad smell from the sore
  • Redness or warmth around the sore
  • Swelling around the sore
  • Tenderness around the sore
  • Fever or chills
  • Mental confusion or difficulty concentrating
  • Rapid heartbeat
  • Weakness

Diagnosis

Bedsores are diagnosed by a physical examination.

Treatment

Specific treatment of a bedsore is based on the severity of the condition. Treatment may be more difficult once the skin is broken and may include:

• Relieving pressure on the affected area that caused the sore
• Protecting the sore with medicated gauze or other special dressings
• Keeping the sore clean
• Transplanting healthy skin to the wound area
• Medication i.e. antibiotics to treat infections
• Improving nutrition and other conditions to help the sore heal

To relieve pressure on the sore:

• Don't lie on bedsores.
• Use foam pads or pillows to take pressure off the sore. Special mattresses, mattress covers, foam wedges or seat cushions can help support you in bed or in a chair to reduce or relieve pressure.
• Try to avoid resting directly on your hip bone when you're lying on your side. Use pillows under one side so that your weight rests on the fleshy part of your buttock instead of your hip bone. Use pillows to keep your knees and ankles apart. When lying on your back, place a pillow under your lower calves to lift your ankles slightly off the bed. Change position at least every two hours.
• When sitting in a chair or wheelchair, sit as upright and straight as you are able. An upright position will allow you to move more easily and help prevent new sores. If you cannot move by yourself, have your caregiver shift your position at least every hour.

In order to heal, bedsores must be kept clean and free of dead tissue:

• Clean the sore by rinsing the area with a salt-water solution. Your doctor or nurse can show you how to clean your bedsore.
• Bedsores should be kept covered with a bandage or dressing. Sometimes gauze is used, which must be kept moist and changed at least once a day. New kinds of dressings include a see-through film and a hydrocolloid dressing, which is a bandage made of a gel that molds to the bedsore. These dressings can stay on for several days.
• Dead tissue (which may look like a scab) in the sore can interfere with healing and lead to infection. There are many ways to remove dead tissue from the bedsore. Rinsing the sore every time you change the bandage is helpful. Special dressings that help your body dissolve the dead tissue can also be used. They are left in place for several days. Another way to remove dead tissue is to put wet gauze bandages on the sore and allow them to dry. The dead tissue sticks to the gauze and is removed when the gauze is pulled off. Sometimes dead tissue must be removed surgically.
• Removing dead tissue and cleaning the sore can hurt. Your doctor can suggest a pain reliever for you to take 30 to 60 minutes before your dressing is changed.

Treating infection

Treatment of an infected bedsore depends on the severity of the infection. If only the sore itself is infected, an antibiotic ointment can be put on the sore. When bone or deeper tissue is infected, intravenous antibiotics are often required.

Nutrition

Good nutrition is important because it helps your body heal the sore. Your doctor, nurse or dietitian can give you advice about a healthy diet. Tell your doctor if you have lost or gained weight recently.

Outcome

As a bedsore heals, it slowly gets smaller. Less fluid drains from it and new, healthy tissue starts growing at the bottom of the sore. This new tissue is pink and looks lumpy and shiny. It may take two to four weeks of treatment before you see these signs of healing. Bedsores are often resistant to treatment, sometimes taking months to improve. The condition can result in prolonged hospitalisation.

Some chronic diseases, such as diabetes and atherosclerosis (hardening of the arteries), make it difficult for bedsores to heal because of a poor blood supply to the area.

If left untreated, severe bedsores can cause deep tissue necrosis, infection and death.

Prevention

The best treatment for bedsores is prevention, which can be achieved by you and/or your caregiver taking the following steps:

• Avoid prolonged pressure on one part of your body, especially the common pressure points mentioned earlier. Relieve pressure on sensitive areas by turning at least every two hours, and apply protective padding at bony prominences. Wheelchair users should try to shift position every 10-15 minutes. Different people do have different pressure tolerances, however, depending on many factors including how bony you are, your circulation, skin condition, age, general health and history of pressure problems. Test to see how long you can lie comfortably in one position. Depending on your skin tolerance and the type of mattress you use, you may be able to spend from as little as two hours to a maximum of eight hours in any one position. If red marks develop, and these last longer than 20 to 30 minutes, you have exceeded your pressure tolerance. It is not advisable to spend more than eight hours in any one position.
• Keep your skin clean with a mild soap and warm (not hot) water and dry it thoroughly. Apply moisturizers so your skin doesn't get too dry.
• Check your whole body every day for spots, colour changes or other signs of sores. Pay special attention to the pressure points where sores are most likely to occur.
• Keep as active as possible and have regular massages to encourage circulation, lymphatic drainage and cellular regeneration. However, avoid massaging the skin over bony prominences.
• Ensure you eat a well-balanced, nutritious diet.
• Change bedclothes frequently and use soft, wrinkle-free sheets.
• Keep the head of the bed at the lowest position possible, depending on your medical condition and other restrictions. Avoid sitting up in bed with the back raised for longer than 30 minutes at time. Shearing forces will cause the skin over the coccyx (tailbone) to break down.
• Check the effectiveness of your pressure-relieving mattress if you use one. Mattresses may be made from foam, fibre, water, air cells or various combinations of these. Check the manufacturer’s instructions for information on maintenance.
• Caregivers should use lifting devices such as a trapeze or bed linen to turn or transfer patients, rather than dragging them.

When to call the doctor

If you or someone in your care has a condition that puts them at risk for bedsores, discuss with your doctor how this may best be avoided. Consult your doctor if you suspect the development of a bedsore (see "symptoms and signs").

If you notice any signs of infection, call your doctor immediately (see "symptoms and signs").

(Reviewed by Prof Don du Toit)