A guide to pressure ulcers known also as pressure sores, or bed sores. They occur when the skin and underlying tissue becomes damaged. In very serious cases, the underlying muscle and bone can also be damaged.
Pressure ulcers may be referred to as pressure sores, bed sores, or decubitus ulcers.
People who are unable to move some or all of their body due to illness, paralysis or advanced age often develop pressure ulcers. Pressure ulcers/sores are a major factor in the deaths of tens of thousands of people each year.
How common are pressure ulcers?
Pressure ulcers are a widespread and often underestimated health problem. For example, in the UK, it’s estimated that between four and 10% of all patients admitted to hospital will develop at least one pressure ulcer. For elderly people with mobility problems, the figure can be as high as 70%.
Even with the best possible medical and nursing care, pressure ulcers can be difficult to prevent in particularly vulnerable people.
In some cases, pressure ulcers present a minor inconvenience that can be treated with some simple nursing care. However, sometimes they can cause extensive damage to the skin, and lead to life-threatening infections, such as wide-spread infection of the blood (sepsis) and tissue death (gangrene).
There are two main goals when caring for people who are at risk of developing pressure ulcers. These are:
- to attempt to prevent the development of pressure ulcers by using special dressings and equipment, and by regularly changing a patient’s position, and
- to treat existing pressure sores by cleaning them and by using antibiotics, improved nutrition and, in the most severe cases, surgery.
Symptoms of pressure ulcers
The areas that are most at risk of developing pressure sores are the parts of the body that are not covered by a high level of body fat and are in direct contact with a supporting surface, such as a bed, or wheelchair.
For example, if you are bed bound, you are at risk of developing pressure ulcers on:
- your shoulders, or shoulder blades,
- your elbows,
- the back of your head,
- the rims of your ears,
- your knees, ankles, heels, or toes,
- your lower back, or hipbone,
- the genitals (in men), and
- the breasts (in women).
If you are a wheelchair user, you are at risk of developing pressure ulcers on:
- your buttocks,
- your tailbone (the small bone at the bottom of your spine),
- your spine,
- your shoulder blades, and
- the back of your arms and legs.
Grading of pressure ulcers
Health professionals use a grading system to describe the severity of pressure ulcers. These grades are described below.
A grade one pressure ulcer is the most superficial type of ulcer. The affected area of skin appears discoloured and is red in white people, and purple, or blue, in people with darker coloured skin.
In a grade one pressure ulcer, the skin remains intact, but it may hurt, or itch, and may feel either warm and spongy, or hard to the touch.
In a grade two pressure ulcer, some of the outer surface of the skin (the epidermis) or the deeper layer of skin (the dermis) is damaged, leading to skin loss. The ulcer looks like an open wound, or a blister.
In a grade three pressure ulcer, skin loss occurs throughout the entire thickness of the skin and the underlying tissue is also damaged. The underlying muscles and bone are not damaged. The ulcer appears as a deep cavity-like wound.
A grade four pressure ulcer is the most severe type of ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, or bone, may also be damaged.
People with grade four pressure ulcers have a high risk of developing a life-threatening infection.
Useful Books about pressure ulcers
Fast Facts about Pressure Ulcer Care
for Nurses: How to Prevent, Detect, and
Resolve Them in a Nutshell
Causes of pressure ulcers
Pressure ulcers develop when sustained pressure interrupts the blood supply to parts of the body. Blood contains oxygen and other nutrients that are required to keep tissue healthy. Without a constant supply of blood, tissue damage occurs and the tissue will eventually die.
Pressure ulcers do not develop in people with normal mobility because the body automatically makes hundreds of regular movements which prevent pressure from building up on any one part of the body. For example, when you are asleep, you may think that you are lying still, but it is not uncommon to shift position up to twenty times a night.
If a person’s is unable to move regularly – for example, due to illness, injury, or paralysis, pressure ulcers can quickly develop, sometimes over the course of a few hours.
Types of pressure
There are three main types of pressure that can lead to the development of pressure ulcers. These are listed below.
- Interface pressure – is the pressure of the body pressing down on the skin onto a firm surface.
- Shear – is pressure that occurs when layers of skin are forced to slide over one another or deeper layers of tissue. Shear can occur when you slide down, or are pulled up out of a bed, or wheelchair.
- Friction – is pressure that is caused by something, such as a mattress, or clothing, rubbing against the surface of the skin.
Moisture is another risk factor for pressure ulcers. It can irritate the skin and make it more vulnerable to damage. This is the reason why people with urinary or bowel incontinence have an increased risk of getting pressure ulcers.
Risk factors for pressure ulcers
The known risk factors for the development of pressure ulcers are listed below.
- Mobility problems – problems moving, or being unable to change position without assistance.
- Inability to feel pain – in a part, or all, of the body, as a result of nerve damage.
- A poor diet – a lack of nutrition can weaken the immune system and slow the healing process.
- Smoking – reduces your blood’s ability to carry oxygen around the body.
- Having a pre-existing health condition that affects the blood circulation system, such as diabetes, or arteriosclerosis (hardening of the arteries).
- Weight loss, or muscle loss – reduced levels of fat and muscle result in the skin being placed under a higher level of pressure.
- Being elderly – elderly people tend to have thinner skin and reduced levels of muscle and fat.
- Having a health condition such as cerebral palsy that causes muscle spasms, or stiffness. Spasms and stiffness will place your skin under increased shear and friction pressure.
- Having spinal damage which means that you will be unable to move some, or all, of your body.
Diagnosing pressure ulcers
Pressure ulcers are easily diagnosed by visual examination. However, the goal of pressure ulcer management is to prevent ulcers occurring in the first place, so an important part of the diagnostic process is to assess your level of risk for developing them.
As part of the risk assessment process, the health professionals involved in your care will consider:
- your general health,
- your ability to move,
- whether you have any problems that may affect your posture,
- whether you have any symptoms that may indicate the presence of infection,
- your mental health,
- whether you have had pressure ulcers in the past,
- whether you are incontinent,
- your diet, and
- how well your blood circulation system is working.
As part of this risk assessment, you may be referred for blood and urine tests. Blood tests can be a good way of assessing your general state of health and whether your diet is providing enough nutrition.
Urine tests can be used to check how well your kidneys are working and whether you have a urinary tract infection (an infection of the kidneys, bladder, or urethra). These types of infection can be of concern if your are incontinent, or if you have experienced spinal damage.
If it thought that you are at risk of developing pressure ulcers, but you are currently not staying in a primary care setting, such as a hospital, or care a home, you may be advised to carry out regular daily checks for evidence of the early signs of pressure ulcers.
You should look out for areas of discoloration and patches of skin that feel unusually spongy, or tough to the touch. Using a mirror can be helpful for checking parts of your body that can be hard to see, such as your back or buttocks.
If you notice any possible signs of damage, you should contact your GP or your healthcare team.
Treating pressure ulcers
Your care team:
As pressure ulcers are a complex health problem, arising from many inter-related factors, your care may be provided by a care team made up of many different types of health professionals. This type of team is sometimes known as a multi-disciplinary team (MDT).
Possible members of a MDT may include:
- an incontinence advisor,
- a social worker,
- a physical therapist,
- a dietitian,
- a urologist (a doctor who specialises in treating conditions that affect the urinary system),
- a gastroenterologist (a doctor who specialises in treating conditions that affect the bowel),
- a plastic surgeon,
- a orthopaedic surgeon (a surgeon who specialises in the treatment of conditions that affect the joints and bones), and
- a neurosurgeon (a surgeon who specialises in the treatment of conditions that affect the brain and nervous system).
Regularly moving your body and changing your position is one of the best ways to prevent pressure ulcers developing, and relieving pressure on grade one and grade two pressure ulcers.
Once your risk assessment has been completed, your care team will draw up a ‘repositioning timetable’ which will state how often you need to be moved. For some people, this may be as often as once every 15 minutes, while others may need to be moved only once every two hours.
A nurse or physical therapist may also give you training and advice about:
- correct sitting and lying positions,
- how you can adjust your sitting and lying position,
- how often you need to move or be moved,
- how best to support your feet,
- how to keep a good posture, and
- the special equipment that you should use and how to use it.
Mattresses and cushions
A range of special mattresses and cushions are available that can be used to relieve pressure on vulnerable parts of the body.
People who are thought to be at risk of developing pressure ulcers, or who have pre-existing grade one or two pressure ulcers usually benefit from resting on a specially designed foam mattress which relieves the pressure on their body.
People with a grade three, or four, pressure ulcer will require a more sophisticated mattress, or bed system. For example, there are mattresses that can be connected to a constant flow of air, which is automatically regulated in order to reduce pressure as and when required.
Specially designed dressings and bandages are available that can be used to protect pressure ulcers and speed up the healing process.
Examples of these types of dressing include:
- hydrocolloid dressings – which are dressings that contain a special gel that encourages the growth of new skin cells in the ulcer while keeping the surrounding area healthy skin dry, and
- alginate dressings – which are dressings that are made from seaweed and contain sodium and calcium, which are known to speed up the healing process.
Topical preparations, such as cream and ointments, can be used to help speed up the healing process while also preventing further tissue damage. A type of chemical, known as oxygen-free radical scavengers, can help prevent cell damage at the genetic level.
If you have a pressure ulcer, you may be given antibiotics to prevent them becoming infected by bacteria and, as a precaution, to prevent a secondary infection developing.
Antiseptic cream may also be applied directly to any pressure ulcers to clear out any bacteria that may be present.
Certain dietary supplements, such as protein, zinc, and vitamin C have been shown to accelerate wound healing. If your diet lacks these vitamins and minerals, your skin may become more vulnerable to the development of pressure ulcers.
As a result of this, you may be referred to a dietitian so that a suitable dietary plan can be drawn up for you.
In some cases, it may be necessary to remove dead tissue from the ulcer in order to stimulate the healing process. This is known as debridement.
If there is a small amount of dead tissue, it may be possible to remove it using specially designed dressings and paste.
Larger amounts of dead tissue may be removed using mechanical means. Some mechanical debridement techniques include:
- cleansing and pressure irrigation – where dead tissue is removed using high-pressure water jets,
- ultrasound – where dead tissue is removed using low-frequency energy waves, and
- laser – where dead tissue is removed using focused beams of light.
Maggot therapy – also known as larvae therapy – is an alternative method of debridement. Maggots are ideal for debridement because they feed on dead and infected tissue without touching healthy tissue. They also help fight infection by releasing substances that kill bacteria and stimulate the healing process.
During maggot therapy, the maggots are mixed into a wound dressing and the area is then covered with gauze. After a few days, the dressing is taken off and the maggots are removed.
Sometimes, it may not be possible for a grade 3, or grade 4, pressure ulcer to heal, and surgery will be required to seal the wound and prevent any further tissue damage occurring.
A widely used surgical technique for the treatment of pressure ulcers is known as flap replacement (sometimes referred to as flap reconstruction). During this technique, the surgeon will use a scalpel to debride the ulcer of dead tissue. A flap of skin and muscle is then taken from another part of the body and is used to seal the site of the ulcer.
Flap replacement surgery can be challenging, and it is often made more difficult by the fact that most people who undergo the procedure are already in a poor state of health. As a result of these risk factors, there are a large number of possible complications that can arise after surgery including:
- tissue death of the implanted flap
- muscle weakness,
- recurrence of the pressure ulcers,
- blood infection,
- infection of the bone,
- internal bleeding,
- abscesses, and
- deep vein thrombosis.
Despite the high risk of complications, surgery is often a clinical necessity in order to prevent life-threatening complications of pressure ulcers developing, such as blood poisoning, or gangrene.
Preventing pressure ulcers
As part of your treatment plan, your care team will discuss with you the best way to prevent pressure ulcers. This will be based on your individual circumstances. However, you may find that the general advice listed below is helpful.
Making regular and frequent changes to your position is one of the most effective ways of preventing pressure ulcers. As a general rule, wheelchair users will need to change their position at least once every 15-30 minutes. People who are confined to bed will need to change their position at least once every two hours.
If you are unable to change position yourself, a carer, or relative, will be required to assist you. See the ‘treatment’ section for more information about positional changes.
Eating a healthy diet that contains an adequate amount of protein and a good variety of vitamins and minerals can help prevent skin damage occurring and speed up the healing process. You may be referred to a dietitian so that a diet plan can be drawn up for you.
If you are currently experiencing a reduced appetite, due to a pre-existing health condition, you may find the advice below useful.
- Try eating smaller meals throughout the day, rather than two or three larger meals. Setting a timetable highlighting when you should eat, rather than waiting until you feel hungry, should help to ensure that you receive the nutrition that your body needs.
- Limit fluids during your meals because this can make you feel fuller than you actually are. Drink most of your fluids 30-60 minutes before you have a meal.
- If you find swallowing difficult, try drinking specially made nutritional drinks, or pureed foods and soups.
- If you are a vegetarian, it is important that you eat high-protein alternatives to meat. Cheese, yoghurt, peanut butter, custard, beans and nuts are all good sources of protein.
If you are a smoker, giving up is one of the most effective ways to prevent developing pressure ulcers. Smoking reduces the levels of oxygen in your blood, as well as weakening your immune system, increasing your risk of getting pressure ulcers.
Complications of pressure ulcers
Even with the best possible medical care, complications (which can occasionally be life-threatening) can arise from grade three or grade four pressure ulcers. These complications are listed below.
Infection can spread from the site of the pressure ulcer to a deeper layer of skin. This type of infection is known as cellulitis and causes symptoms of pain and redness, plus swelling of the skin.
Left untreated, there is a risk that the infection can spread to the blood (blood poisoning or sepsis) or the membranes that surround the brain and spine (meningitis), both of which are life threatening conditions.
Cellulitis will need to be treated using a course of antibiotics.
If a person with a weak immune system has a pressure ulcer that becomes infected, there is a risk that the infection will spread into their blood and other organs. This is known as blood poisoning, or sepsis.
In the most serious cases of blood poisoning, damage to multiple organs can lead to a large drop in blood pressure, which is known as septic shock. Septic shock can be fatal and symptoms include cold skin and an increased heart beat.
Blood poisoning is a medical emergency and requires immediate treatment in an intensive care unit (ICU) so that the functions of the body can be supported while the infection is treated with antibiotics, or antiviral medication.
Bone and joint infection
Infection can also spread from a pressure ulcer downward into underlying joints (septic arthritis) and bones (osteomyelitis).
Both of these infections can cause damage to cartilage, tissue, and bone, and may affect the function of the joints and limbs. Antibiotics are required to treat bone and joint infections and, in the most serious of cases, infected bones and joints may need to be surgically removed.
Necrotizing fasciitis, commonly known as ‘flesh-eating’ bacteria, is a serious skin infection that causes rapid tissue death. Necrotizing fasciitis can occur when a pressure ulcer becomes infected with a type of bacteria known as Group A streptococcus bacteria.
Emergency treatment is required and involves a combination of antibiotics and surgical debridement of the dead tissue.
Gas gangrene is a rare, but serious, form of infection that occurs when a pressure ulcer becomes infected with the clostridium bacteria. The bacteria thrives in environments where there is little, or no, oxygen. They produce gases and release dangerous toxins. Symptoms of gas gangrene include rapid swelling of the skin and severe pain.
Gas gangrene requires immediate treatment with surgical debridement and, in the most serious of cases, it may be necessary to amputate the affected body part in order to prevent the gangrene from spreading to the rest of the body.