Too often, people associate the word “bedsore” with the concept of neglect and abuse, to the detriment of careful—and caring—health care providers. It’s true that skin ulcerations can be painful for patients and terrifying for families. And while they’re preventable, bedsores—more formally known as pressure sores, pressure injuries, or decubitus ulcers—are sometimes difficult to treat and can occur despite excellent clinical care. Because bedsores are often feared by patients and their families, it may help to understand the physiological mechanisms that can cause them, as well as measures that can be taken to prevent them.
A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. Areas most at risk include the sacrum (tailbone), ischium (the lower, back side of the hip bones), hips, heels, and elbows. Pressure ulcers are caused by prolonged pressure on the prominence, or pressure in combination with shear, such as a dragging or brushing motion.

RISK FACTORS: Because these ulcers are caused by pressure, any condition that contributes to increased or prolonged pressure presents a risk for the development of ulcers. Some examples include bed-bound or chair-bound conditions, impaired ability to reposition oneself, obesity, inactivity, and immobility.
Patients with disorders that decrease the amount of blood flow to the affected areas are at increased risk of developing pressure ulcers, or experiencing worsened symptoms. Examples of such disorders include anemia, emaciation, malnutrition, diabetes, cardiac disease, blood vessel disease, sickle cell anemia, and cancer.
Advanced age results in decreased collagen, decreased fat under the skin, and decreased skin elasticity, all of which increase the risk for pressure ulcers. Both dry and moist skin can also lead to skin breakdown.

APPEARANCE: The appearance of a pressure wound will vary with its stage. A standardized staging system is used to name the amount of tissue loss.

• Stage 1: Non-blanchable erythema—a reddened area that does not turn white when pressed.
• Stage 2: Partial thickness skin loss—a shallow open ulcer with red/pink wound bed. It may also present as an intact or open/ruptured blister.
• Stage 3: Full thickness skin loss in which the fat under the skin may be visible.
• Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. These wounds are at risk for developing osteomyelitis, an infection of the bone.
• Unstageable/Unclassified: The wound is completely obscured by slough (dead tissue) and/or eschar (black scab). The true depth cannot be determined, but it will either be a Stage 3 or 4.
• Suspected Deep Tissue Injury: Depth unknown. The wound presents as a purple or maroon localized area of discolored intact skin, or a blood-filled blister, due to damage of underlying soft tissue from pressure and/or shear. The evolution of this type of injury may progress rapidly, exposing additional layers of tissue even with optimal treatment.

TREATMENT AND PREVENTION: The treatment for pressure ulcers depends largely on their stage, size, and location. Ulcers can be treated conservatively in the early stages—for example, by relieving pressure. Ulcers in more advanced stages may require special dressings; surgical, mechanical or other methods of debridement; or other treatments, depending on severity.

Pressure ulcer prevention should focus on decreasing pressure on bony prominences, improving skin condition, and improving nutrition. Measures to decrease pressure on at-risk areas include frequent repositioning, pressure-redistributing mattresses, chair cushions, pillows or foam wedges to keep bony prominences from direct contact with each other, and positioning heels off the mattress.

Skin condition can be improved or maintained with the use of mild cleansing agents, application of lotions, frequent incontinence care, and the use of moisture-absorbing briefs.

Nutrition should be addressed by increasing protein and carbohydrate intake, staying well hydrated, and providing supplements such as a multi-vitamin with minerals, vitamin C, zinc and protein supplements. Stabilizing underlying health conditions, such as diabetes and cardiac disease, will also promote tissue health.

Preventing and treating pressure ulcers is complex, and they cannot always be avoided. But with an understanding of their physiological causes and possible interventions, providers and families can work together to find the best treatment and achieve the best outcome for patients. When it comes to skin ulcers, knowing the facts can help alleviate emotional upset and prevent unnecessary claims and allegations—a win for everyone involved.