Pressure Ulcers (Bedsores)

How pressure ulcers form

When skin is squeezed between a bone and a mattress or chair, the small blood vessels are pressed shut. Without blood flow, the tissue runs out of oxygen. In vulnerable people, damage can begin within a few hours. Deeper tissue such as muscle is more sensitive than skin, so damage can be worse underneath than it looks on the surface.

Three other forces add to the damage:

• Shear: skin stays still while the body slides, as when someone slips down in bed with the head raised
• Friction: rubbing against sheets during moves
• Moisture: sweat, urine or stool softens skin and makes it break down faster

Who is at risk

• People who are bedbound or use a wheelchair, after surgery, stroke, hip fracture or spinal cord injury
• Reduced sensation, as in diabetes, nerve damage or paralysis, so the person does not feel the need to move
• Dementia or heavy sedation
• Urinary incontinence or fecal incontinence
• Poor nutrition, low weight or dehydration (malnutrition)
• Older age, thin and fragile skin, poor circulation and smoking
• Medical devices pressing on skin, such as oxygen tubing, casts, splints or catheters

Hospitals and care homes use scoring tools such as the Braden Scale, which rates sensation, moisture, activity, mobility, nutrition and friction, to identify people at risk.

Early signs of bedsores

Check the skin over bony areas at least once a day. Look and feel for:

• Redness that does not fade: press the red area gently with a finger for a few seconds. If it does not turn pale (it is "non-blanching"), damage has begun
• In darker skin: redness may not show. Look for purple, blue or darker patches, and feel for warmth, coolness, firmness or a boggy, spongy texture compared with nearby skin
• Pain, itching or burning at a pressure point
• Blisters, peeling or a shallow open area

Stages of pressure ulcers

For more on stages, complications and medical treatment of deep wounds, see decubitus ulcer.

How to prevent bedsores

Keep changing position

• In bed: turn at least every 2 hours, more often if the skin shows redness. Use a tilted side position at about 30 degrees rather than lying directly on the hip bone.
• Head of the bed: keep it at 30 degrees or lower when possible, to reduce sliding and shear.
• Heels: "float" them by placing a pillow under the calves so the heels touch nothing.
• In a chair: shift weight every 15 minutes if able, by leaning forward or side to side. People who cannot do this should be repositioned at least every hour.
• Use a draw sheet or slide sheet to lift rather than drag.

Use the right equipment

• A pressure-redistributing mattress (high-specification foam, air or alternating-pressure mattress) for anyone at high risk
• A pressure-relieving cushion for wheelchair users
• Pillows or foam wedges between knees and ankles
• Do not use ring or "donut" cushions, which concentrate pressure on the surrounding skin

Look after the skin

• Clean skin promptly after incontinence with a gentle, pH-balanced cleanser and pat dry
• Apply a barrier cream or film to protect from moisture
• Keep sheets dry and free of wrinkles and crumbs
• Do not massage red areas over bones; this can damage tissue further

Nutrition and hydration

Protein, calories, fluids, vitamins and minerals are all needed to maintain skin and heal wounds. A dietitian may recommend high-protein supplements for people who are underweight or not eating well.

Treatment

Stage 1 and 2

• Remove all pressure from the area by repositioning and using pressure-relieving surfaces
• Clean gently with saline and cover open areas with a moist dressing such as a hydrocolloid or foam, as advised by a nurse
• Protect surrounding skin and treat incontinence
• Most heal within days to a few weeks once pressure is removed

Stage 3, 4 and unstageable

• Care from wound specialists, doctors and nurses
• Debridement: removal of dead tissue, by dressings, enzymes or surgery (stable dry black scabs on heels are sometimes left in place)
• Advanced dressings, and sometimes negative pressure wound therapy (a vacuum dressing)
• Antibiotics only when there is spreading infection, cellulitis or bone infection
• Surgery with skin or muscle flaps for some deep ulcers in people well enough for it
• Pain control before dressing changes

Healing of stage 3 and 4 ulcers often takes months, and some never fully close, especially in people near the end of life.

Complications

• Infection of skin and soft tissues, including cellulitis
• Bone and joint infection (osteomyelitis)
• Sepsis, which can be life-threatening
• Long hospital stays, pain and loss of independence

Frequently asked questions

What do the early signs of bedsores look like?

The earliest sign is a patch of skin over a bony area that stays red, or purple or darker on brown and Black skin, and does not fade when pressed. The area may feel warmer, cooler, firmer or softer than surrounding skin, or be painful or itchy. Act immediately by removing pressure.

How often should a bedbound person be turned?

A common standard is at least every 2 hours in bed, adjusted to the person's skin response and the type of mattress. Wheelchair users who cannot shift their own weight need repositioning at least every hour. Check the skin at each turn and turn more often if redness persists.

How do you treat a bedsore at home?

Take all pressure off the area, keep it clean with saline, cover open sores with a dressing recommended by a nurse, manage moisture and improve nutrition. Home care suits stage 1 and early stage 2 sores. Deeper, worsening or infected sores need medical assessment.

How long does it take for a pressure ulcer to heal?

Stage 1 areas can recover within a few days once pressure is relieved. Stage 2 sores usually heal in 1 to 3 weeks. Stage 3 and 4 ulcers commonly take 1 to 6 months or longer, and healing depends on removing pressure, nutrition, infection control and overall health.

Can bedsores be prevented completely?

Most can. Regular repositioning, pressure-redistributing mattresses and cushions, daily skin checks, managing incontinence and good nutrition prevent the large majority. Some people who are critically ill or dying may develop skin breakdown despite excellent care because their circulation and tissue are failing.