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Diseases and Conditions
Bedsores (Pressure sores)
From MayoClinic.com
Special to CNN.com

Introduction

In 1995, a horse riding accident transformed Christopher Reeve from an actor indelibly identified with Superman into a quadriplegic and an outspoken advocate for the disabled. Ten years later, Reeve's death from complications of a pressure sore called attention to one of the most serious problems facing people with disabilities.

Bedsores, more accurately called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure — usually from a bed or wheelchair — cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips and heels. Without adequate blood flow, the affected tissue dies.

Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop pressure sores.

Pressure sores can develop quickly, progress rapidly and are often difficult to heal. Yet health experts say many of these wounds don't have to occur. Key preventive measures can maintain the skin's integrity and encourage healing.

Signs and symptoms

Pressure sores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:

  • Stage I. Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.
  • Stage II. At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.
  • Stage III. By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.
  • Stage IV. In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.

If you use a wheelchair, you're most likely to develop a pressure sore on:

  • Your tailbone or buttocks
  • Your shoulder blades and spine
  • The backs of your arms and legs where they rest against the chair

When you're bed-bound, pressure sores can occur in any of these areas:

  • The back or sides of your head
  • The rims of your ears
  • Your shoulders or shoulder blades
  • Your hip bones, lower back or tailbone
  • The backs or sides of your knees, heels, ankles and toes

Causes

You shift in your chair during meetings, fiddle with the radio when driving, turn a dozen times in your sleep. Every day, without thinking, you make hundreds of subtle postural adjustments that help stave off problems arising from inactivity. But for people immobilized by paralysis, injury or illness, those problems — including pressure sores — are a constant threat.

Pressure sores usually result from sustained pressure on your body. They're especially common in areas that aren't well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows. Because your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur. Though the affected tissue may die in as little as 12 hours, the injury may not be apparent for days or even weeks.

In some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, crumbs in your bed, wrinkled clothing or sheets, a chair whose tilt is slightly off — even perspiration, which can soften skin, making it more vulnerable to injury.

Other causes of pressure sores include:

  • Friction. Frequent shifts in position are the key to preventing pressure sores. Yet the friction that occurs when you simply turn from side to side can damage your skin, making it more susceptible to pressure sores.
  • Shear. This occurs when your skin moves in one direction, and the underlying bone moves in another. Sliding down in a bed or chair or raising the head of your bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as your tailbone where skin is already thin and fragile.

Risk factors

If you're immobilized by acute illness, injury, or sedation — even for a brief time such as after an operation or accident — you can develop pressure sores. But people living with spinal cord injuries are at greatest risk.

Because the nerve damage from these injuries is often permanent, compression of skin and other tissues is ongoing. Exacerbating the problem are thinning or atrophied skin and decreased circulation, both of which make tissue damage more likely and healing more difficult. And because spinal cord injuries reduce or eliminate sensation, you don't receive the body signals that tell you to shift your position or that a sore is developing.

If you're unable to move certain parts of your body without help for any reason, one or more of these factors may increase your risk of pressure sores:

  • Age. The majority of pressure sores occur in people older than 70. Older adults tend to have thinner skin than younger people do, making them more susceptible to damage from minor pressure. They're also more likely to be underweight, with less natural cushioning over their bones. And poor nutrition, a serious problem among older adults, not only affects the integrity of the skin and blood vessels, but also hinders wound healing. Even with optimum nutrition and good overall health, wounds tend to heal more slowly as you age, simply because the repair rate of your cells declines.
  • Residence in a nursing home. In general, nursing home residents have higher rates of bedsores than do people who are hospitalized or cared for at home, in part because nursing home residents may be especially frail. On the other hand, rates are much higher for certain groups of hospitalized patients — quadriplegics, older adults recovering from hip fractures and people in critical care.
  • Lack of pain perception. Loss of sensation is usually due to spinal cord injuries or disease, but it can also result from certain medications. Whatever the cause, an inability to feel pain means you're not aware when you're uncomfortable and need to change your position or that a bedsore is forming.
  • Natural thinness or weight loss. You often lose weight when you're sick or hospitalized, and muscle atrophy and wasting are common in people living with paralysis. In either case, you lose fat and muscle that help cushion your bones. Some experts say the best way to prevent skin breakdown is to have at least two inches of muscle over bony areas.
  • Urinary or fecal incontinence. Problems with bladder control can greatly increase your risk of pressure sores because your skin stays moist, making it more likely to break down. And bacteria from fecal matter can not only cause serious local infections but also lead to life-threatening systemic complications such as sepsis, gangrene and necrotizing fasciitis, a severe and rapidly spreading infection.
  • Malnutrition. You're more likely to develop pressure sores if you have a poor diet, especially one deficient in protein, zinc and vitamin C. You're also more likely to have recurrent pressure sores, more severe infections and slower healing wounds than are people with healthier diets.
  • Other medical conditions. Because certain health problems such as diabetes and vascular disease affect circulation, parts of your body may not receive adequate blood flow, increasing your risk of tissue damage. And if you have muscle spasms (spastic paralysis) or contracted joints, you're subject to repeated trauma from friction and shear forces.
  • Smoking. Smokers have a higher incidence of pressure sores than nonsmokers do. They also tend to develop more severe wounds and to heal more slowly, mainly because nicotine impairs circulation and reduces the amount of oxygen in your blood. The risk increases with the number of years and cigarettes smoked.
  • Decreased mental awareness. People whose mental awareness is lessened by disease, trauma or medications are often less able to prevent or care for pressure sores.

When to seek medical advice

Carefully inspect your skin at least once a day, paying particular attention to your spine, tailbone and other bony places. Because the early signs of skin damage aren't always clear, it's best to also feel your skin, noting any spots that are unusually firm, spongy or warm to the touch. If you can't look for pressure sores yourself, a family member, nurse or caregiver should do it for you.

If an area of your skin is red or discolored but not broken, keep pressure off the sore, wash it gently with mild soap and water, dry thoroughly, and apply a protective wound dressing. If the sore doesn't heal in a week or two, if it recurs, or if you notice any broken skin or open sores, contact your doctor right away.

Get immediate medical care if you have signs of infection: fever, drainage from the sore, a foul odor or increased heat and redness in the surrounding skin.

Screening and diagnosis

Pressure sores are usually unmistakable, even in the initial stages, but your doctor is likely to order blood tests to check your nutritional status and overall health. Depending on the circumstances, you may have other tests, including:

  • Urine analysis and culture. A sample of your urine may be examined for various reasons, but you're especially likely to have this test if you have a problem with incontinence. The test also checks for kidney problems and urinary tract infections, which may be a particular concern for people with spinal cord injuries.
  • Stool culture. In cases of fecal incontinence, a sample of your stool may be sent to a laboratory for analysis.
  • Biopsy. When you have a wound that doesn't improve, even with intensive treatment, or you have chronic pressure sores, your doctor may remove a small sample of tissue that allows for a complete bacterial evaluation. The tissue may also be checked for cancer, which is a risk in people with long-standing wounds.

Complications

Every year, complications of pressure sores kill tens of thousands of Americans, including one in 12 people living with spinal cord injuries. Even the most conscientious care can't always prevent serious or life-threatening infections of your skin, muscle or bone. Complications include:

  • Cellulitis. This acute infection of your skin's connective tissue causes pain, redness and swelling, all of which can be severe. Cellulitis can also lead to life-threatening complications, including sepsis and meningitis — an infection of the membrane and fluid surrounding your brain and spinal cord.
  • Bone and joint infections. These develop when the infection from a pressure sore burrows deep into your joints and bones. Joint infections (septic or infectious arthritis) can damage cartilage and tissue within days, whereas bone infections (osteomyelitis) may fester for years if not treated. Eventually, bone infections can lead to bone death and reduced function of your joints and limbs.
  • Necrotizing fasciitis. This rapidly spreading infection destroys the layers of tissue that surround your muscles. Initial signs and symptoms include fever, pain and massive swelling. Without treatment, death can occur in as little as 12 to 24 hours.
  • Gas gangrene (myonecrosis). A rare and severe form of gangrene, myonecrosis develops suddenly and dramatically and spreads so rapidly that changes in tissue are noticeable within minutes. The Clostridium bacteria responsible for gas gangrene produce toxins that completely destroy affected muscle tissue and cause potentially fatal systemic problems.
  • Sepsis. One of the greatest dangers of an advanced pressure sore, sepsis occurs when bacteria from a massive infection enter your bloodstream and spread throughout your body — a rapidly progressing, life-threatening condition that can cause shock and organ failure.
  • Cancer. This is usually an aggressive carcinoma affecting the skin's squamous cells. Often, it may have spread to the lymph nodes by the time it's diagnosed.

Treatment

As challenging as preventing pressure sores is, treating them is even more daunting. Open wounds are slow to close, and because skin and other tissues have already been damaged or destroyed, healing is never perfect.

Addressing the many aspects of wound care, including those that are emotional and social, requires a multidisciplinary approach. You're likely to receive care from nurses, and your primary care physician, along with help from a social worker and physical therapist. When incontinence is an issue, you may see a urologist or gastroenterologist. And if a wound requires surgical repair, a neurosurgeon, orthopedic surgeon and plastic surgeon may be involved in your care.

Conservative treatment
Although it may take some time, most stage I and stage II sores will heal with conservative measures. But stage III and stage IV wounds, which are much less likely to resolve on their own, often require surgery.

The first step in treating a sore at any stage is relieving the pressure that caused it. You can reduce pressure by:

  • Changing positions often. Carefully follow your schedule for turning and repositioning — approximately every 15 minutes if you're in a wheelchair and at least once every two hours when you're in bed. If you're unable to change position on your own, a family member or other caregiver must be able to help. Using sheepskin or other padding over the wound can help prevent friction when you move.
  • Using support surfaces. These are special cushions, pads, mattresses and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown. The most effective support depends on many factors, including your level of mobility, your body build and the severity of your wound. No one support surface is appropriate for all people or all situations. In general, protective padding such as sheepskin isn't thick enough to reduce pressure, but it's helpful for separating parts of your body and preventing friction damage. You can use a variety of foam, air-filled or water-filled devices to cushion a wheelchair, but avoid using pillows and rubber rings, which actually cause compression. If you have a stage I or stage II sore, an air or water mattress or foam overlay may provide enough padding for your bed. But for multiple lesions, sores that won't heal or severe wounds, doctors often suggest low-air-loss beds or air-fluidized beds. Low-air-loss beds use inflatable pillows for support, whereas air-fluidized beds suspend you on an air-permeable mattress that contains millions of silicon-coated beads.

Other nonsurgical treatments of pressure sores include:

  • Cleaning. It's essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Saline solution is available at the drugstore, or you can make it at home by boiling 1 teaspoon of salt in 1 quart of water for five minutes. Store the solution in a sterile container and cool before using. Avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.

    Controlling incontinence as far as possible is crucial to helping sores heal. If you're experiencing bladder or bowel problems, you may be helped by lifestyle changes, behavioral programs, incontinence pads or medications.

  • Removal of damaged tissue (debridement). To heal properly, wounds need to be free of damaged, dead or infected tissue. This can be accomplished in several ways — the best approach depends on your overall condition, the type of wound and your treatment goals. One approach is surgical debridement, a procedure that involves using a scalpel or other instrument to remove dead tissue. Surgical debridement is quick and effective, but it can be painful. For that reason, your doctor may use one or more nonsurgical approaches. These include removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), allowing your body's own enzymes to break down dead tissue (autolytic debridement), or applying topical debriding enzymes (enzymatic debridement).
  • Dressings. A variety of dressings are used to help protect wounds and speed healing — the type usually depends on the stage and severity of the wound. The basic approach, however, is to keep the wound moist and the skin surrounding it dry. Stage I sores may not need any covering, but stage II lesions are usually treated with hydrocolloids, or transparent semipermeable dressings that retain moisture and encourage skin cell growth. Other types of dressings may be more beneficial for weeping wounds or those with surface debris. Contaminated sores may also be treated with a topical antibiotic cream.
  • Hydrotherapy. Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue.
  • Healthy diet. Eating a nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals — especially vitamin C and zinc — has been shown to improve wound healing. Being well nourished also protects the integrity of your skin and guards against breakdown. If you're at risk of or recovering from a pressure sore, your doctor may prescribe vitamin C and zinc supplements, which you can find at natural food stores and most pharmacies.
  • Muscle spasm relief. This is essential for both preventing and treating pressure sores. To help alleviate spasticity, your doctor may recommend skeletal muscle relaxants that block nerve reflexes in your spine or in the muscle cells themselves.

Surgical repair
Even with the best medical care, bedsores can quickly reach a point where they require surgical intervention. 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 future cancer.

The type of reconstruction that's best in any particular case depends mainly on the location of the wound and whether there is scar tissue from a previous operation. In general, though, most pressure wounds are reconstructed using a pad of muscle, skin or other tissue that covers the wound and cushions the affected bone. The tissue is usually harvested from your own body.

Before the operation, the wound is debrided, although much more extensively than it is in nonsurgical treatments. In addition to dead tissue, the fluid-filled sac that serves as a gliding surface between bone and muscle (bursa) is removed, along with any diseased bone.

In spite of every precaution, flap reconstruction has one of the highest complication rates of any surgery, and the recovery period is long and arduous. You must have a strong social support system, optimal nutritional status, state-of-the-art resources such as a pressure-release bed, and the ability and motivation to participate in your own recovery to be a candidate for this operation.

Other treatment options
Researchers are searching for more effective pressure sore treatments. Under investigation are hyperbaric oxygen, electrotherapy and the topical use of human growth factors. Growth factors — proteins that stimulate cell growth — have been approved for the treatment of diabetic ulcers but not, as yet, for pressure sores.

Prevention

Pressure sores are easier to prevent than to treat, but that doesn't mean the process is easy or uncomplicated. Still, although wounds can develop in spite of the most scrupulous care, it's possible to prevent them in many cases.

The first step is to work with your nurses and doctor to develop a plan that you and your caregiver(s) can follow. The cornerstones of such a plan include position changes along with supportive devices, daily skin inspections, and a maximally nutritious diet.

Position changes
Changing your position frequently and consistently is crucial to preventing pressure sores. It takes just a few hours of immobility in a wheelchair or bed for a pressure sore to begin to form. For that reason, experts advise shifting position every 15 to 30 minutes that you're in a wheelchair and at least once every two hours, even during the night, if you spend most of your time in bed. If you can't move on your own, a family member or caregiver must be available to help you.

A physical therapist can advise you on the best ways to position yourself in bed, but here are some general guidelines:

  • Avoid lying directly on your hipbones. On your side, lie at a 30-degree angle.
  • Support your legs correctly. When lying on your back, place a foam pad or pillow — not a doughnut shaped cushion — under your legs from the middle of your calf to your ankle. Avoid placing a support directly behind your knee — it can severely restrict blood flow.
  • Keep your knees and ankles from touching. Use small pillows or pads.
  • Avoid raising the head of the bed more than 30 degrees. A higher incline makes it more likely that you'll slide down, putting you at risk of friction and shearing injuries. If the bed needs to be higher when you eat, place pillows or foam wedges at your hips and shoulders to help maintain alignment.
  • Use a pressure-reducing mattress or bed. You have many options, including foam, air, gel or water mattresses. Because these can vary widely in price and effectiveness, talk to your doctor about the best choice for you. For some people, a low air loss mattress may provide enough support. But more expensive and technologically sophisticated beds may be needed for people who have recurring pressure sores or who are at very high risk.

Pressure-release wheelchairs, which tilt to redistribute pressure, make sitting for long periods easier and more comfortable. If you don't have a pressure-release chair, you or your caregiver will need to manually change your position every 15 to 30 minutes. If you have movement and enough strength in your upper body, you can do wheelchair pushups — raising your body off the seat by pushing on the arms of the chair.

All wheelchairs need cushions that reduce pressure and provide maximum support and comfort. Various cushions are available, including foam, gel, and water- or air-filled cushions. Although they may help relieve pressure, cushions and other devices don't prevent pressure sores from forming or replace the need to change your position as often as recommended.

Skin inspection
Daily skin inspections for pressure sores are an integral part of prevention. Inspect your skin thoroughly at least once a day, using a mirror if necessary. Some experts suggest examining your skin twice a day or with every repositioning. A family member or caregiver can help if you're not able to do it yourself.

If you're confined to bed, pay special attention to your hips, spine and lower back, shoulder blades, elbows and heels. When you're in a wheelchair, look especially for sores on your buttocks and tailbone, lower back, legs, heels and feet. If you see skin damage or any sign of infection such as drainage from a sore, a foul odor, and increased tenderness, redness and warmth in the surrounding skin, get medical help immediately.

Nutrition
A healthy diet is important in preventing skin breakdown and in aiding wound healing. Unfortunately, the people most likely to develop pressure sores are also often the most malnourished.

If you're ill, recovering from surgery or living with paralysis, you may have little appetite and eating may be physically difficult. Yet it's essential to get enough calories, protein, vitamins and minerals. A dietitian can help devise an eating plan that caters to your food preferences while supplying necessary nutrients. These measures also may help:

  • Try smaller meals. If you feel full after eating only a small amount, try eating small meals more frequently when you do get the urge to eat. If you never seem to feel hungry, it's often helpful to eat according to a schedule rather than to rely on appetite.
  • Take advantage of the times when you feel your best. Eat a larger meal when you're hungry. Many people have their best appetite in the morning, when they're rested.
  • Limit fluids during meals. Liquids can fill you up and prevent you from eating higher calorie foods. It may help to drink most of your liquids 30 to 60 minutes before or after you eat. Don't restrict your intake of water overall, however. It helps keep skin soft and supple.
  • Consider pureed or liquid meals. If swallowing is difficult, emphasize soups, pureed foods or nutritional supplement drinks, which provide protein and calories but require little or no preparation. It may be easier for you to drink rather than to eat something.
  • Consider protein alternatives. If meat isn't appealing to you, consider other high-protein foods such as cottage cheese, peanut butter, yogurt and custards. Beans and nuts also are good protein sources but may be hard to digest.
  • Find a comfortable position. Raise the head of your bed to a comfortable level while you eat.
  • Don't rush. Allow sufficient time for meals, and if you need assistance, don't let your caregiver rush you.

Lifestyle changes
Although you may need assistance with many aspects of your care, you can take control of some important preventive measures, including:

  • Quitting smoking. Ask your doctor about the most effective way to stop smoking. Tobacco use decreases oxygen to your skin, robs your body of vitamin C and slows wound healing.
  • Exercise. Daily exercise improves circulation, builds up vital muscle tissue, stimulates your appetite and strengthens your body overall. A physical therapist can recommend an exercise program tailored to your needs.
  • Support. Your physical and emotional well-being depend on having a strong support system. Don't be afraid to ask for help with daily tasks or for emotional support.

For the family
If you have a loved one in a nursing home, hospital or other care facility, check that person's skin condition, weight and general care every time you visit. If you notice any sign of pressure sores or neglect, alert the nursing staff and attending physician or nursing home director immediately. You and other family members are in the best position to monitor and assess a loved one's condition.

March 18, 2005

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