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Pressure Ulcers And Bed Sores: Prevention And Treatment

It can be easy to take your skin for granted—until it breaks down, leaving you more vulnerable to pain, infection and even necrosis (dead tissue). Pressure ulcers, also referred to as pressure sores, bed sores and decubitus ulcers, are forms of “pressure injuries,” common conditions that affect up to 30% of people living in nursing homes and up to 23% of hospitalized people [1] Raetz JGM, Wick KH. Common questions about pressure ulcers. American Family Physician. 2015;92(10):888-894. .

Just because you don’t see an ulcer doesn’t mean a pressure injury hasn’t occurred. In fact, skin and soft tissue are damaged before an ulcer appears. By recognizing pressure injuries early, you may be able to prevent ulceration. Here’s what you need to know.

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What Are Pressure Ulcers?

When you stay in a certain position in a bed or a chair for an extended period of time, the areas of your skin and soft tissue underneath it that are resting on the surface can become damaged. It can also occur with clothing or medical equipment that is resting or pushing on your skin. This damage is known as a pressure injury. When the skin and soft tissue underneath break down, leaving an open wound, a pressure ulcer is present.

“Skin is the largest organ of the body—and the most complex,” says Jeffrey M. Levine, M.D., associate clinical professor of geriatric medicine and palliative care at the Icahn School of Medicine at Mount Sinai in New York. “Its jobs are to regulate body temperature and water balance, take in information about your environment, protect against injury and infection, and support your endocrine system by producing vitamin D and processing sex hormon­es,” he says.

“The skin is adversely affected by aging, sunlight, exposure to chemicals, certain drugs (including corticosteroids), malnutrition and diseases like diabetes that affect the circulatory system,” he adds. “When people become immobile, physical forces like pressure, friction and shear can compromise circulation and cause damage to the skin.”

Who’s Most Likely to Get a Pressure Ulcer?

Pressure injuries and pressure ulcers are most common among people who are in the hospital or live in long-term care facilities, such as nursing homes and rehabilitation centers. As many as 200 factors can put a person at risk for pressure injuries and pressure ulcers, but some of the most common include [2] Bogie KM, Phil D, Zhang GQ, et al. Individualised clinical practice guidelines for pressure injury management: development of an integrated multi-modal biomedical information resource. JMIR Research Protocols. 2018;7:e10871. :

  • Limited mobility, such as that caused by a broken bone or a condition that causes paralysis
  • Poor circulation
  • Edema (swelling)
  • Poor health and nutrition
  • Exposure to moisture and/or acid (from sweat, urine or feces)
  • Advanced age
  • Cognitive impairment
  • Chronic conditions, such as heart disease and depression
  • Substance use disorder

Pressure Ulcer Symptoms

The symptoms of a pressure injury and pressure ulcer vary and depend on the extent of skin and tissue damage. They include:

  • A feeling of warmth or coolness in the skin
  • A feeling of tenderness
  • A feeling of firmness or softness compared to the surrounding area
  • A noticeable odor
  • Pain

“In general, pressure injuries cause pain and local discomfort,” says Dr. Levine. “Pain can be caused by changes in position needed to apply wound dressings and remove dressings that are sticking to the wound, and by the wound itself. Moisture or infection caused by fungus or bacteria can also cause discomfort.”

Some people may experience no pain at all, says Dr. Levine. “For example, people who are paralyzed may have a severe pressure injury but not feel it because of nerve damage.”

The 4 Stages of Pressure Ulcers

Healthcare providers diagnose and treat pressure injuries in several ways. One common system stems from the National Pressure Injury Advisory Panel (NPIAP), which describes four stages of pressure injury.

Stage 1
At this stage, a pressure injury may look like a patch of red or irritated skin. The person with the injury may notice the skin feels warmer or cooler or firmer or softer than the skin surrounding the irritated area. The irritation and redness are caused by small blood vessels in the area broken by pressure.

Stage 2
The skin may be blistered or appear broken in a stage 2 pressure injury. The wound is superficial with partial-thickness skin loss.

Stage 3
At this stage, an ulcer has developed, and there is an open wound that’s deeper compared to a stage 2 ulcer. Bone and muscle aren’t yet visible at this stage.

Stage 4
Bone and muscle can be seen in a stage 4 pressure injury. There may also be some necrotic (dead) tissue visible at this stage.

Common Pressure Ulcer Sites

Pressure injuries can happen anywhere on the body and can be caused by the body’s own weight or by pressure caused by medical equipment like a face mask or an oxygen tube. Some common places where pressure ulcers appear include:

  • Ears
  • Back of the head
  • Shoulders
  • Elbows
  • Buttocks
  • Hips
  • Heels
  • Tops of feet
  • Lower back

How to Prevent Pressure Ulcers

Many pressure injuries can be prevented with a team approach involving doctors, nurses, caregivers and patients themselves. Effective strategies include:

  • Managing or improving underlying conditions, such as diabetes and vascular problems that can cause slow healing and poor circulation.
  • Looking at and caring for the skin every day. Inspect the skin for signs of injury and use a pH-balanced cleanser and moisturizer as often as needed.
  • Repositioning the patient and their medical devices and clothing regularly to ensure no single part of the body is exposed to pressure for an extended period of time.
  • Improving nutritional status—the patient may benefit from a dietary supplement.

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Best Treatments for Pressure Ulcers

It’s important to see a healthcare professional as soon as possible when you notice skin irritation or any other sign of a pressure injury. “In general, wound care needs to be supervised by a professional,” says Dr. Levine. “Wounds need to be assessed on a regular basis to recognize and document changes. They may get better, or they may get worse. Necrosis (dead tissue) or infection can develop, and blood tests or imaging tests may be necessary to inform future treatment.”

While basic dressing changes can be done at home by a family member or non-medical caregiver, care must be supervised by a professional. “There are many types of dressings, and they must be applied and removed correctly. Incorrect use of dressings can cause additional damage to the wound and surrounding skin,” says Dr. Levine.

Finally, it’s important to remember other aspects of treatment and prevention may require a professional. “Pressure redistribution, continence care, nutrition and mobilization also need to be addressed,” says Dr. Levine.

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