How to Prevent and Treat Bed Sores
Anyone who remains lying or sitting in one position for more than a couple of hours is at risk for skin breakdown. This can lead to pressure sores, which are also known as pressure ulcers or bedsores. These skin problems can be painful and decrease a person’s quality of life.
Causes of Bed Sores
Someone who cannot change position in bed or is limited to sitting in a chair needs to be helped to change position every hour or two.
Repositioning, pressure reduction, and good skin care are all necessary to prevent skin problems and to keep small problems from getting worse.
Bedsores are caused by pressure against the skin that limits blood flow to the skin and nearby tissues. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores.
Three primary contributing factors of bed sores are:
- Sustained pressure. When your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or a bed, the pressure may be greater than the pressure of the blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to tissues. Without these essential nutrients, skin cells and tissues are damaged and may eventually die.
- This kind of pressure tends to happen in areas that aren’t well-padded with muscle or fat and that lie over a bone, such as your spine, tailbone, shoulder blades, hips, heels and elbows.
- Friction. Friction is the resistance to motion. It may occur when the skin is dragged across a surface, such as when you change position or a care provider moves you. The friction may be even greater if the skin is moist. Friction may make fragile skin more vulnerable to injury.
- Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a hospital bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction. This motion may injure tissue and blood vessels, making the site more vulnerable to damage from sustained pressure.
Risk of Bed Sores
People are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to:
- Generally poor health or weakness
- Injury or illness that requires bed rest or wheelchair use
- Recovery after surgery
Other factors that increase the risk of pressure sores include:
- Age. The skin of older adults is generally more fragile, thinner, less elastic and drier than the skin of younger adults. Also, older adults usually produce new skin cells more slowly. These factors make skin vulnerable to damage.
- Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of bedsores or the need to change position.
- Weight loss. Weight loss is common during prolonged illnesses, and muscle atrophy and wasting are common in people with paralysis. The loss of fat and muscle results in less cushioning between bones and a bed or a wheelchair.
- Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.
- Excess moisture or dryness. Skin that is moist from sweat or lack of bladder control is more likely to be injured and increases the friction between the skin and clothing or bedding. Very dry skin increases friction as well.
- Bowel incontinence. Bacteria from fecal matter can cause serious local infections and lead to life-threatening infections affecting the whole body.
- Medical conditions affecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage.
- Smoking. Smoking reduces blood flow and limits the amount of oxygen in the blood. Smokers tend to develop more-severe wounds, and their wounds heal more slowly.
- Limited alertness. People whose mental awareness is lessened by disease, trauma or medications may be unable to take the actions needed to prevent or care for pressure sores.
- Muscle spasms. People who have frequent muscle spasms or other involuntary muscle movement may be at increased risk of pressure sores from frequent friction and shearing.
Stages of Bed Sores and Pressure Sores
Bedsores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization that promotes the prevention and treatment of pressure ulcers, defines each stage as follows:
Stage I Bed Sores
- The beginning stage of a pressure sore has the following characteristics:
- The skin is not broken.
- The skin appears red on people with lighter skin color, and the skin doesn’t briefly lighten (blanch) when touched.
- On people with darker skin, the skin may show discoloration, and it doesn’t blanch when touched.
- The site may be tender, painful, firm, soft, warm or cool compared with the surrounding skin.
Stage II Bed Sores
- The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost.
- The wound may be shallow and pinkish or red.
- The wound may look like a fluid-filled blister or a ruptured blister.
Stage III Bed Sores – the ulcer is a deep wound:
- The loss of skin usually exposes some fat.
- The ulcer looks crater-like.
- The bottom of the wound may have some yellowish dead tissue.
- The damage may extend beyond the primary wound below layers of healthy skin.
Stage IV Bed Sores – ulcer shows large-scale loss of tissue:
- The wound may expose muscle, bone or tendons.
- The bottom of the wound likely contains dead tissue that’s yellowish or dark and crusty.
- The damage often extends beyond the primary wound below layers of healthy skin.
Unstageable Bed Sores
A pressure ulcer is considered unstageable if its surface is covered with yellow, brown, black or dead tissue. It’s not possible to see how deep the wound is.
- Deep tissue injury
- A deep tissue injury may have the following characteristics:
- The skin is purple or maroon but the skin is not broken.
- A blood-filled blister is present.
- The area is painful, firm or mushy.
- The area is warm or cool compared with the surrounding skin.
- In people with darker skin, a shiny patch or a change in skin tone may develop.
Common Sites of Bed Sores and Pressure Sores
For people who use a wheelchair, pressure sores often occur on skin over the following sites:
- Tailbone or buttocks
- Shoulder blades and spine
- Backs of arms and legs where they rest against the chair
For people who are confined to a bed, common sites include the following:
- Back or sides of the head
- Rim of the ears
- Shoulders or shoulder blades
- Hip, lower back or tailbone
- Heels, ankles and skin behind the knees
When to See a Doctor for Bed Sores or Pressure Sores
If you notice early signs or symptoms of a pressure ulcer, change your position to relieve the pressure on the area. If you don’t see improvement in 24 to 48 hours, contact your doctor. Seek immediate medical care if you show signs of infection, such as fever, drainage or a foul odor from a sore, or increased heat and redness in the surrounding skin.
Complications of Pressure Ulcers
- Sepsis. Sepsis occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It’s a rapidly progressing, life-threatening condition that can cause organ failure.
- Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. Cellulitis can lead to life-threatening complications.
- Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications.
- Cancer. Another complication is the development of a type of squamous cell carcinoma that develops in chronic, nonhealing wounds (Marjolin ulcer). This type of cancer is aggressive and usually requires surgery.
Treatment for Bedsores
Stage I and II bedsores usually heal within several weeks to months with conservative care of the wound and ongoing, appropriate general care. Stage III and IV bedsores are more difficult to treat.
Addressing the many aspects of wound care usually requires a multidisciplinary approach. Members of your care team may include:
- A primary care physician who oversees the treatment plan
- A physician specializing in wound care
- Nurses or medical assistants who provide both care and education for managing wounds
- A social worker who helps you or your family access appropriate resources and addresses emotional concerns related to long-term recovery
- A physical therapist who helps with improving mobility
- A dietitian who monitors your nutritional needs and recommends an appropriate diet
- A neurosurgeon, orthopedic surgeon or plastic surgeon, depending on whether you need surgery and what type
Reducing Pressure to Heal Bed Sores
The first step in treating a bedsore is reducing the pressure that caused it. Strategies include the following:
- Repositioning. If you have a pressure sore, you need to be repositioned regularly and placed in correct positions. If you use a wheelchair, try shifting your weight every 15 minutes or so. Ask for help with repositioning every hour. If you’re confined to a bed, change positions every two hours.
- If you have enough upper body strength, try repositioning yourself using a device such as a trapeze bar. Caregivers can use bed linens to help lift and reposition you. This can reduce friction and shearing.
- Using support surfaces. Use a mattress, bed and special cushions that help you lie in an appropriate position, relieve pressure on any sores and protect vulnerable skin. If you are in a wheelchair, use a cushion. Styles include foam, air filled and water filled. Select one that suits your condition, body type and mobility.
Cleaning and Dressing Bed Sore Wounds
Care that helps with healing of the wound includes the following:
Cleaning. It’s essential to keep wounds clean to prevent infection. If the affected skin is not broken (a stage I wound), gently wash it with water and mild soap and pat dry. Clean open sores with a saltwater (saline) solution each time the dressing is changed.
Applying dressings. A dressing promotes healing by keeping a wound moist, creating a barrier against infection and keeping the surrounding skin dry. Dressing choices include films, gauzes, gels, foams and treated coverings. A combination of dressings may be used.
Your doctor selects a dressing based on a number of factors, such as the size and severity of the wound, the amount of discharge, and the ease of placing and removing the dressing.
Removing Damaged Bed Sore Tissue
To heal properly, wounds need to be free of damaged, dead or infected tissue. Removing this tissue (debridement) is accomplished with a number of methods, depending on the severity of the wound, your overall condition and the treatment goals.
- Surgical debridement involves cutting away dead tissue.
- Mechanical debridement loosens and removes wound debris. This may be done with a pressurized irrigation device, low-frequency mist ultrasound or specialized dressings.
- Autolytic debridement enhances the body’s natural process of using enzymes to break down dead tissue. This method may be used on smaller, uninfected wounds and involves special dressings to keep the wound moist and clean.
- Enzymatic debridement involves applying chemical enzymes and appropriate dressings to break down dead tissue.
Other interventions that may be used are:
- Pain management. Pressure ulcers can be painful. Nonsteroidal anti-inflammatory drugs — such as ibuprofen (Motrin IB, Advil, others) and naproxen (Aleve, others) — may reduce pain. These may be very helpful before or after repositioning, debridement procedures and dressing changes. Topical pain medications also may be used during debridement and dressing changes.
- Antibiotics. Infected pressure sores that aren’t responding to other interventions may be treated with topical or oral antibiotics.
- A healthy diet. To promote wound healing, your doctor or dietitian may recommend an increase in calories and fluids, a high-protein diet, and an increase in foods rich in vitamins and minerals. You may be advised to take dietary supplements, such as vitamin C and zinc.
- Management of incontinence. Urinary or bowel incontinence may cause excess moisture and bacteria on the skin, increasing the risk of infection. Managing incontinence may help improve healing. Strategies include frequently scheduled help with urinating, frequent diaper changes, protective lotions on healthy skin, and urinary catheters or rectal tubes.
- Muscle spasm relief. Spasm-related friction or shearing can cause or worsen bedsores. Muscle relaxants — such as diazepam (Valium), tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen (Gablofen, Lioresal) — may inhibit muscle spasms and help sores heal.
- Negative pressure therapy (vacuum-assisted closure, or VAC). This therapy uses a device that applies suction to a clean wound. It may help healing in some types of pressure sores.
Surgery for Bed Sores and Pressure Sores
A pressure sore that fails to heal may require surgery. The goals of surgery include improving the hygiene and appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of cancer.
If you need surgery, the type of procedure depends mainly on the location of the wound and whether it has scar tissue from a previous operation. In general, most pressure sores are repaired using a pad of your muscle, skin or other tissue to cover the wound and cushion the affected bone (flap reconstruction).
Preventing Bed Sores at Home
- Look at the person’s skin daily. Tell the health care team about any changes you notice, such as red areas. These are the first signs of skin breakdown, and will lead to sores if left untreated.
- Clean skin daily.
- If the person uses an adult incontinence brief, clean the skin under the brief each time it is changed. Protect skin with a moisture barrier cream. These products often contain zinc or silicone.
- Use mild cleansing products.
- Avoid using hot water to clean the skin.
- Use moisturizers for dry skin.
- Check to make sure clothing and bed linens are clean, dry and free of wrinkles. Wrinkles increase friction and may lead to skin discomfort or pain.
Bedsore Pressure Reduction
- Relieve any constant pressure on areas at greatest risk for skin breakdown. These include the site of existing pressure sores, the site of previously healed sores, scars, and bony areas.
- If the person is in bed, remind, or help, the person to change position every two hours.
- If the person is in a chair or wheelchair, remind, or help, the person to change position every hour. If possible, help the person stand briefly, or alternate between sitting and lying. It is best if the person avoids sitting for long periods.
- Use pillows like this repositioning wedge between legs, under arms or elsewhere. This separates bony areas, prevents direct skin-on-skin contact, and may make swollen legs and ankles feel better.
- Have the person avoid lying directly on the side, that is, with the front of the body facing sideways, at right angles to the mattress. A better position is to lie slightly sideways, that is, using supporting pillows to help the front of the body tilt about thirty degrees to the mattress.
- Avoid using air rings or other donut-shaped cushioning devices.
- Ask your local home care or palliative care program if they have a loan program for pressure-reducing mattresses.
How to Move Someone in Bed
Some people may find it uncomfortable to be moved, but staying in the same position for more than a couple of hours may lead to even greater pain or discomfort.
Changing positions is important, except in cases when someone may not live more than a few hours. These are some general tips for moving someone in bed.
If possible, watch a member of the care team do a move, so you can see how it is done.
If the person finds it painful to be moved, talk to the health care team about giving the person pain medication beforehand. They can tell you the best type of medication to use for this purpose, and explain how and when to give it.
Moving someone from one position to another is easier with two people, with each standing on opposite sides of the bed.
Take care to keep your knees slightly bent (not locked) when you do any sort of lifting. This gives your back proper support.
When moving a person, lift the person off the surface below, rather than dragging the person in direct contact with the surface.
Moving someone is much easier if the person is lying on a turning sheet or a cloth absorbent pad.
Turning sheets are small sheets that run from the person’s head to buttocks.
Any sheet can be made into a turning sheet by folding it in half and laying it over the full sheet. The sheet or pad allows two people to grab onto the corners to lift or move the person on the bed.
Recommended: SafetySure MovEase Under Pad
After the move, pull on the sheet or pad from top to bottom, to smooth out wrinkles.
Before starting a move, lower the bed to a flat position, or recline the bed as far as the person’s condition allows. Lower the bed slowly, as rapid movements can cause discomfort.
Moving Someone From Their Back Onto Their Side
Place a pillow under the person’s head before starting the turn and have pillows ready to place under legs, arms, and behind the back.
If the person is going to be turned onto the right side, take the left arm, bend it gently at the elbow, and place it over the stomach.
Bend the left leg at the knee, and place a pillow between the person’s legs.
Place one hand behind the person’s buttocks and the other underneath the shoulder.
Roll the person in the direction of your helper, and have the helper hold the person in place.
Once the helper is holding the person, place your hands under the person’s buttocks to move the body back toward the center of the bed.
You may need to pull the right (bottom) shoulder forward if it looks uncomfortable. This places the person in more of a fetal position rather than lying completely straight.
Arrange the pillows comfortably between the person’s shoulder and head, and also between the legs. When you return the person onto their back later, place a pillow under the head and one under each shoulder, positioned to make the person as comfortable as possible.
Raising Someone in Bed With a Turning Sheet
People who are sitting up in bed will naturally slide down over time. Before you raise the person, lower the bed until it is flat, or as flat as the person’s condition allows.
If possible, ask the person to tuck their chin into their neck during the move, so their head is protected.
Take hold of a bottom and top of the turning sheet on your side, and have your helper do the same on the other side.
On a signal, such as the count of three, gently lift the person toward the head of in bed.
Once the bed is raised again to a comfortable position, you can place a pillow under the person’s knees to prevent slipping.
Raising Someone in Bed Without aTurning Sheet
Stand near the person’s shoulder, with your helper on the opposite side.
Look toward the head of the bed, and place one of your arms under the person’s shoulder closest to you.
Use your free arm to support yourself by leaning into the bed.
On a signal, such as the count of three, lift the person toward the head of bed.
If possible, ask the person to bend their knees and dig into the bed with their heels to help with the move.
Once the bed is raised again to a comfortable position, you can place a pillow under the person’s knees to prevent slipping.
Remember, it is much easier to prevent bedsores with proper care at home, than to treat a bedsore once it has developed.
Watch for signs of pressure points and reduce pressure with regular turning and moving, and examine the skin for signs of pressure.
If you have had experience dealing with bedsores, please share your thoughts below.
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