Bedsores sometimes referred to as pressure sores or pressure ulcers are wounds that develop when constant pressure or friction on one area of the body damages the skin. This constant pressure on an area of the skin tends to stop the normal flow of blood, so the cells die and the skin breaks down. The sores can affect any part of the body, but often the bony areas around the elbows, knees, hips, tailbone, ankles, and heels are more susceptible. If left untreated or not treated successfully, these sores can develop into more serious problems that are difficult to cure and in some cases, an infection can even prove fatal.
People most at risk of bedsores are those with medical conditions that cannot allow them to make even the slightest of movements, spending most of their time in a bed or chair. Also, the elderly or frail individuals often with thin skin tend to be more at risk of contracting bedsores. Bedsores can develop quickly. Although most sores heal with treatment, some never heal completely.
Warning signs and symptoms of bedsores
Pressure sores can appear on any part of the skin that has prolonged contact with an object exerting pressure like a bed or wheelchair. The signs of a pressure sore include:
- Unusual changes in skin color or texture
- Skin that is either abnormally warm or cool to the touch
- Significant pain, tingling or itching on any part of the body
- A painful red area on the skin that does not turn white when pressed
- The skin blisters or forms an open sore. With the area around the sore being red and irritated
- Pus-like draining
- A crater-like appearance
- Deep injury to tissues that can affect the muscles, tendons, and bones
- Broken skin or an open wound
Causes of bedsores
Bedsores are caused by pressure against the skin thus limiting blood flow. Limited mobility in bedridden patients or those in wheelchairs for long periods makes the skin vulnerable to damage and contribute to the development of pressure sores. The primary contributing factors for bedsores are:
Pressure
Continuous pressure on any part of your body against a surface can lessen the blood flow to tissues. Uninterrupted blood flow is essential to delivering oxygen and other nutrients to tissues. Without these nutrients, the skin and nearby tissues get damaged and might eventually die. For the patients with limited mobility, this kind of pressure tends to happen in the areas that are not well- padded with muscle or fat and that lie over a bone, such as, hips, heels, shoulder blades, elbows, and spine.
Friction
Where the skin rubs against bedding or clothing, then friction occurs. This can make fragile skin more vulnerable to injury especially if the skin is moist or wet from fluids like sweat or urine.
Shear
Pressure sores are often likely to develop when you are elderly. As you age, your skin tends to become thinner and more easily damaged. Shear thus occurs when two surfaces move in the opposite direction. For instance, when a bed is elevated at the head, you can slide down the bed. As your tailbone moves down, the skin over the bone might stay in place, essentially pulling in the opposite direction causing a painful and uncomfortable feeling.
Risk factors associated with bedsores
Bedsores risk assessment is crucial to the prevention of pressure ulcers. Many factors may put certain patients at higher risk of developing this painful condition that increases health care costs and can lead to prolonged hospitalization, and in worst-case scenarios cause deaths. Some of the risk factors include;
Poor mobility/immobility
Patients who are unable to independently change position because of health conditions such as spinal cord injury, coma or paralysis, are at an increased risk of developing bedsores due to pressure exerted over bony prominences which result in reduced blood flow to the tissues and subsequent hypoxia.
Age
As people grow older, their skin tends to become thinner, drier and less elastic. These make the skin vulnerable to injury.
Poor nutritional status and hydration
Patients with poor nutritional status experience loss of fatty tissue which serves as a cushion over pressure-sensitive areas. Malnutrition leads to decreased resilience of skin tissue and decreased exposure time to develop a pressure ulcer. People need enough fluids, protein, calories as well as minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.
Reduced sensory perception
Patients who do not feel pain or discomfort may not be aware of warning signs and the need to change position. Spinal cord injuries and neurological disorders can result in loss of sensation. The loss in sensation doesn’t allow the patients to feel when pressure is building up.
Poor mental status
Patients who are also suffering from dementia or other cognitive disorders may not be able to comprehend instructions being given that could otherwise help prevent pressure injuries or they may fail to recognize the discomfort as a signal to change position.
Support surfaces
The surface on which the patient lies or sits profoundly influences pressure over bony prominences, as can lying or sitting in the same position for long periods. Thus support surfaces especially those of patients with mobility challenges should be assessed frequently and adjusted accordingly.
Compromised blood flow
When there is poor blood circulation to the tissues, then there is an increased risk of bedsores. Common reasons that might compromise blood flow are peripheral arterial disease, diabetes, smoking, vascular diseases, and shock.
Obesity
Where patients are overweight in combination with, for instance, immobility or being restricted to sitting or lying down, places extra pressure on capillaries, reducing blood flow to the skin thus resulting in bedsores.
Tips for preventing bedsores
If you are currently a patient on bed rest, there are several things you can do to prevent bedsores. These include:
Change positions frequently
When you change positions often, then there will be less pressure on the skin. It is, therefore, a good idea to reposition your body at least every couple of hours to reduce the risk of developing pressure ulcers. For instance, if you have been lying on your back for a while, turn to your side. Where you are unable to switch positions on your own, seek help from your caretaker or a family member.
Keep skin clean and dry
Cleaner and drier skin are less likely to develop bedsores. Frequently wash your skin with warm water and mild soap. Then pat your skin dry with a towel. Do not rub your skin hard as it may lead to skin irritation.
Use pillows
Put pillows between parts of your body that press against each other to avoid shear of the skin which increases the chances of bedsores.
Exercise
The idea of exercise seems daunting especially when you can’t even get out of bed. However, performing a few ranges of motion exercises in bed can help reduce the risk of pressure ulcers. For example, you can start with an arm lift exercise. This is where you lift your arm as high as you can and hold it there for 15 seconds, repeating the exercise on the other arm.
The stages of bedsore
Bedsore or pressure ulcers as they are commonly referred to, are categorized by the National Pressure Ulcer Advisory Panel into four stages. The stages are based on the degree of tissue involvement or the depth of the sore. These four stages are vital in helping doctors determine the best course of treatment for a speedy recovery. If the bedsore is caught early and treated properly, they can heal in a matter of days. The stages are:
Stage one
The first stage is the mildest. It is characterized by the superficial reddening of intact skin that does not blanch when pressed. This means there is an interruption in blood flow and that an ulcer is forming. In this particular ulcer stage, the wound has not yet opened, but the extent of the condition is deeper than just the top of the skin. You may experience mild burning or itching. The affected area may often be sore to touch but has no surface breaks or tears. The texture and temperature of this area will likely also be different from the surrounding normal tissue. People with darker skin may experience visible discoloration. If the pressure is not removed, a stage one bedsore can progress to stage two.
Stage two
In the second stage, the patient will most likely experience some pain from the ulcer. The intact skin suddenly breaks open, exposing the epidermis and sometimes the dermis. The tear resembles an abrasion, popped blister, or shallow crater of skin. The break typically creates a shallow, open wound. Stage two ulcers will usually be red and warm to the touch. There may also exist clear fluid in the broken skin. The surrounding areas of the skin may be swollen, sore, or red. Every effort must be made to pad the sore and alter the body’s position frequently to avoid progression to stage three.
Stage three
At this stage, the sores have broken completely through the top two layers of the skin and into the fatty tissue below. Fat may begin to be visible in the open sore but not muscle, tendon, or bone. The ulcer in this stage may resemble a crater. There may be visible pus and smell in some cases. At this stage, the ulcer opens the body to infection that may lead to serious complications such as osteomyelitis and sepsis. With aggressive and sustained treatment, an ulcer at this stage can resolve in one to four months depending on its size and depth.
Stage four
Stage four ulcers are the most severe and can be extremely painful. They occur when the hypodermis and underlying fascia are breached, exposing muscle and bone. The risk of infection is highest at this stage. At this stage, you can expect to see drainage, dead skin tissue, muscles and sometimes bone. The skin may turn black and notice a dark, hard substance known as eschar which is hardened dead wound tissue in the sore. Stage four ulcers are the most difficult to treat as they require aggressive treatment to avoid systemic infection and other potentially life-threatening complications. According to a 2014 study in Advances in Nursing, mortality rates for elderly people with stage four pressure ulcers may be as high as 60% within a year.
Treatment for bedsores
Once bedsores have developed, immediate treatment is required. Whilst choosing a treatment strategy, consideration should be given to the stage of the wound and the purpose of the treatment. Some of the treatment recommendations are;
Relieve pressure on the area
When sitting in a wheelchair, try to change positions every 15 minutes by leaning forward and side-to-side. If you are in bed, make sure you are moving to a new position every two hours or so. Use pillows or other supports to help relieve pressure and keep you comfortable in different positions.
Cover the sore if needed
Use special dressing or bandage to cover your sore. This helps in preventing infection of the sore which could prove fatal in an already painful condition.
Clean your sore
For the beginning signs of a pressure sore, wash with mild soap and water. If the sore is open, try cleaning with a saline rinse. Afterward, make sure to pat the area dry, rather than rubbing it to avoid irritation.
Take care of your general health
Eat nutritious foods and get lots of sleep to help your body heal. Increased needs for energy, protein, zinc, and vitamins A, C, and E as well as amino acids such as arginine and glutamine have been documented to help in the healing of bedsores. Hydration also plays a vital role in the preservation and repair of skin integrity.
Debridement
This treatment is recommended for more advanced sores and involves the removal of dead tissue with a scalpel, chemical solution, whirlpool bath or biosurgery.
Complications
Untreated bedsores can lead to a wide variety of secondary conditions. These include:
- Bone and joint infections. An infection from bedsore can burrow into joints and bones, damaging cartilage and tissue. This reduces the function of joints and limbs.
- This is an infection of the skin and soft body tissue. It can cause warmth, redness, and swelling of the affected area. Often people with nerve damage do not feel pain in the area affected by cellulitis.
- Long-term non-healing wounds can develop into a type of squamous cell carcinoma.
- Bedsores can lead to sepsis. This is bacteria entering the bloodstream.
Conclusion
If your loved one has been severely injured or is extremely ill, they may need to spend a significant amount of time in bed or a wheelchair. While prolonged immobility can be beneficial to recovery, it can become problematic if it places persistent pressure on vulnerable skin. So unless preventive steps are taken, bedsores, also known as pressure ulcers, are bound to develop. The most common sites for pressure ulcers are the sacrum, heels, and tailbone. They may not only cause pain and discomfort but may lead to infections such as cellulitis and meningitis.
If you are caring for a patient confined to a bed or chair for any period, it is important to be cautious of the risk of bedsores. The best way to prevent skin damage is to reduce the time and pressure that is applied to improve skin quality. Try and develop a plan that the caregiver can follow. This plan should include position changes, supportive devices, daily skincare, a nutritious diet, and lifestyle changes. Besides, a routine nursing assessment is required for people at high risk of pressure sores. Both patients and their support system must realize that it is their responsibility to avoid recurrent as well as new ulceration as this is a lifelong process.
