Pressure ulcer

Areas where bedsores occur

Progression of a decubitis ulcer

Definition

A pressure ulcer is an area of skin that breaks down when constant pressure is placed against the skin.

Alternative Names

Bedsore; Decubitus ulcer

Causes

Pressure against the skin reduces blood supply to that area, and the affected tissue dies. This may happen when you stay in one position for too long without shifting your weight. You might get a pressure ulcer if you use a wheelchair or are confined to a bed, even for a short period of time (for example, after surgery or an injury).

The following factors increase the risk for pressure ulcers:

• Being bedridden or in a wheelchair
• Being older
• Being unable to move certain parts of your body without help, such as after a spine or brain injury or if you have a disease like multiple sclerosis
• Having a chronic condition, such as diabetes or vascular disease, that prevents areas of the body from receiving proper blood flow
• Having a mental disability from conditions such as Alzheimer's disease
• Having fragile skin
• Having urinary incontinence or bowel incontinence
• Not getting enough nourishment (malnourishment)

Symptoms

A pressure ulcer starts as reddened skin that gets worse over time. It forms a blister, then an open sore, and finally a crater.

The most common places for pressure ulcers to form are over bones close to the skin, like the elbow, heels, hips, ankles, shoulders, back, and back of the head.

Pressure sores are categorized by how severe they are, from Stage I (earliest signs) to Stage IV (worst):

• Stage I: A reddened area on the skin that, when pressed, does not turn white. This indicates that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin breakdown now looks like a crater. There is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

First Aid

Discuss any new or changing pressure sore with your doctor or nurse. Once a pressure ulcer is found, the following steps must be taken right away:

• Relieve the pressure on that area. Use pillows, special foam cushions, and sheepskin to reduce the pressure.
• Treat the sore based on the stage of the ulcer. Your health care provider will give you specific treatment and care instructions.
• Avoid further injury or friction to the area. Powder the sheets lightly to decrease friction in bed. (There are many items made for this purpose -- check a medical supplies store.)
• Improve nutrition and other problems that may affect the healing process.
• If the pressure ulcer is at Stage II or worse, your health care provider will give you instructions on how to clean and care for open ulcers. It is very important to do this properly to prevent infection.
• Keep the area clean and free of dead tissue. Your health care provider will give you care directions. Generally, pressure ulcers are rinsed with a salt-water rinse to remove loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers.
• New medicines that promote skin healing are available and may be prescribed by your doctor.

Do Not

• Do NOT massage the area of the ulcer. Massage can damage tissue under the skin.
• Donut-shaped or ring-shaped cushions are NOT recommended. They interfere with blood flow to that area and cause complications.

Call immediately for emergency medical assistance if

Contact your health care provider if an area of the skin blisters or forms an open sore. Contact the provider immediately if there are any signs of an infection. An infection can spread to the rest of the body and cause serious problems. Signs of an infected ulcer include:

• A foul odor from the ulcer
• Redness and tenderness around the ulcer
• Skin close to the ulcer is warm and swollen

Fever, weakness, and confusion are signs that the infection may have spread to the blood or elsewhere in the body.

Prevention

If you are bedridden or cannot move due to diabetes, circulation problems, incontinence, or mental disabilities, you should be checked for pressure sores every day. You or your caregiver need to check your body from head to toe.

Pay special attention to the areas where pressure ulcers often form. Look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters. In addition, take the following steps:

• Change position at least every 2 hours to relieve pressure.
• Use items that can help reduce pressure -- pillows, sheepskin, foam padding, and powders from medical supply stores.
• Eat well-balanced meals that contain enough calories to keep you healthy.
• Drink plenty of water (8 to 10 cups) every day.
• Exercise daily, including range-of-motion exercises.
• Keep the skin clean and dry.
• After urinating or having a bowel movement, clean the area and dry it well. A doctor can recommend creams to help protect the skin.

References

Fonder MA, Lazarus GS, Cowan DA, Aronson-Cook B, Kohli AR, Mamelak AJ. Treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. J Am Acad Dermatol. 2008;58(2):185-206.

Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management. Am Fam Physician. 2008;78(10):1186-1194.

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Review Date: 11/22/2010
Reviewed By: Richard J. Moskowitz, MD, Private Practice, Mineola, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.