Pressure (Decubitus) Ulcers- Bed Sores

(3/4/09) The February 2009 NCHS Data Brief #14 entitled "Pressure Ulcers Among Nursing Home Residents: United States, 2004" indicated that "More than 1 in 10 nursing home residents had a pressure ulcer". This means approximately 159,000 current nursing home residents, representing 11% of the nursing home population, had pressure ulcers.

Pressure ulcers were more common in men than in women. Residents in nursing homes for 1 year or less (16%) were more likely to have pressure ulcers than those with a longer stay. Pressure ulcers were more common in residents under 64 than in those over 65.

Clinical characteristics of those who had pressure ulcers included recent loss of weight, high immobility, polypharmacy (greater than 8 medications), and recent bladder or bowel incontinence.

The report concludes with "Pressure ulcers are serious and common medical conditions in U. S. nursing homes, and remain an important public health problem".

This survey consisted of 1,500 nursing homes stratified for bed size category and metropolitan area sampling. A sample of up to 12 current residents per facility was selected resulting in a total of 14,017 residents.

The report also defines the various stages of pressure ulcers:

Stage 1. A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved.

Stage 2. A partial thickness is lost and may appear as an abrasion, blister, or shallow crater.

Stage 3. A full thickness of skin is lost, exposing the subcutaneous tissues--presents as a deep crater with or without undermining adjacent tissue.

Stage 4. A full thickness of skin and subcutaneous tissue are lost, exposing muscle or bone.

(3/3/08)- Health expert estimate that about two million Americans suffer from pressure ulcers each year, usually because of immobility, poor nutrition, dehydration or incontinence. New research is showing that the battle against this affliction can be handled best through a team approach. Whether it be the doctor, nurse, nurse's aide, relative, friend or anyone who comes in contact with a person who is immobile for whatever reason, they must all be conscious of what they can do to prevent this illness from happening.

The CDC spearheaded a collaborative effort at 52 nursing homes throughout the country wherein every person who has contact with a resident would do whatever they could to prevent pressure ulcers from occurring. The Journal of American Geriatrics Society reported last August that team efforts had reduced the number of severe pressure ulcers acquired in-house by 69%.

"Preventing pressure ulcers is a 24/7/365 kind of job," said Jeff West, a clinical reviewer at Qualis Health in Seattle who helped set up the collaborative in 2003. "It's not as if one person can get it all done. And if it fails just a little bit, just during the weekend, for instance, you're not going to get the results. It takes tremendous consistency."

Dr. Joanne Lynn, who helped begin the project when she was a senior natural scientist with the RAND Corporation, but is now with the CDC, said the goal was to educate nursing home workers in bedsore prevention and to encourage them to come up with creative, low-tech solutions of their own.

There are four stages of pressure ulcers. In Stage 1 and Stage 2 the sores are merely superficial wounds on the skin's surface. In Stage 3 and Stage 4 the wound deepens and can even penetrate down to the bone as a result of the death of the skin and the underlying tissues.

(2/6/03)- Pressure ulcers (A.K.A. decubitus ulcer and bed sores) are a common problem in all health care settings. Anywhere's from 1.3 million to 3 million adults suffer from this problem. Incidence of this problem varies from populations being surveyed: incidence rates for hospitals vary from 0.4% to 38%, while long term care settings vary from 2.2% to 23.9%, and home care reports indicate an incidence rate of 0% to 1.7%. A study by Thomas et al suggests that pressure rates in elderly are associated with increased mortality rates. Federal standards of care in nursing homes and hospitals list pressure sores as one of the quality of care indicators.

Pressure sores develop when persisting pressure on a bony site obstructs healthy capillary flow, leading to tissue necrosis. It is generally accepted that healthy capillary pressure ranges from 20 to 40 mg Hg, with 32 mm Hg considered the average. Pressure ulcers can develop within 2 to 6 hours. The pressure ulcer can range from a very mild pink coloration of the skin, which disappears in a few hours after pressure is relieved on the area, to a very deep wound extending to and sometimes through internal organs and into bone.

All pressure sores have a course of injury similar to a burn wound. This can be a mild redness of the skin and/or blistering such as a first degree burn to a deep open wound with a lot of blackened tissue in it such as a third or fourth degree burn. This black tissue is called eschar. A decubitus ulcer can develop in as little as eight hours in an immobile, debilitated person. (See below for explanation of different stages of pressure ulcers.)

While the usual mechanism of forming a bedsore is from pressure, it can also occur from friction by rubbing against something such as a bed sheet, cast, brace, etc., or from prolonged exposure to cold. Any area of tissue that lies just over a bone is very likely to form a pressure ulcer. These areas include the spine, coccyx or "tailbone," hips, heels, and elbows, to name a few. The weight of the person's body presses on the bone, the bone presses on the skin and tissue that cover it, and the tissue is trapped between the bone structure and bed or wheelchair surface. This situation compresses the blood vessels in the skin and underlying tissues. This tissue then begins to decay from lack of blood circulation.

A contributing factor to the development of pressure ulcers is an altered nutritional state [poor nutrition, weight loss, diabetes, etc.]. Additional contributing factors are poor hygiene, dehydration and immobility sometimes as a result of a poor standard of nursing care.. Diabetes is not a cause of pressure ulcers but rather unrelieved pressure is the cause. However in a diabetic individual the situation may escalate more quickly and be more difficult to control. For this reason diabetic individuals need even greater attention and prevention than non-diabetic individuals.

Stages of pressure ulcer development
These ulcers or wounds are classified according to the severity of the wound, usually in four stages or types:
Stage 1: There is an observable redness of the intact skin. The skin is unbroken, but inflamed and may be painful and warm to the touch. You might also notice the skin's texture may be spongy or firm.

Stage 2: The first sign of skin breakdown occurs with partial skin loss involving the dermis or epidermis or both. The ulcer will look like an abrasion, blister or shallow crater. The outer layer of the skin is broken, red and painful. The surrounding tissue may be pale, red or swollen.

Stages 3 and 4: This is where you have ulcer production. The skin has broken down and there is extensive destruction or damage to the underlying muscle, bone or supporting structures such as tendon and joint capsule.

Ulcers are extremely difficult to heal and may take many months for complete repair. Obviously, anything that can prevent the development of an ulcer should be given consideration. This has resulted in trying to identify risk factors that increase the susceptibility to pressure ulcers. Researchers have identified over 100 risk factors. This lead to the development of pressure ulcer prediction tools, with two-Norton Scale and Braden Scale- the most widely used. The Norton Scale is composed of 5 broad clinical categories: physical condition, mental state, activity, mobility, and incontinence, with a score of 16 or less indicating increased risk for pressure-ulcer development. The Braden is composed of 6 broad clinical categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear, with a score of 18 or less indicating increased risk for pressure-ulcer development. However, using such broad categories for evaluation, results in many false positives, which could increase the costs of dealing with this disorder, besides increasing burden on nursing staff and causing patient anxiety.

In the long run, the most important step to prevent pressure-ulcer is to avoid prolonged pressure on one part of your body, especially the pressure points mentioned previously.
It's also important to keep your skin healthy. Keep your skin clean and dry. Use a mild soap (like Dove, Basis or Oil of Olay) and warm (not hot) water. Apply moisturizers so your skin doesn't get too dry. If you must spend a lot of time in bed or in a wheelchair, check your whole body every day for spots, color changes or other signs of sores. Pay special attention to the pressure points where sores are most likely to occur.

The literature suggests that preventing pressure ulcers requires a broad range of interventions, none of which have had rigorous research evaluation. So one has to start from what is known i.e. excessive pressure for a period of time probably results in pressure-ulcer. It follows from this basic assumption that prevention measures need to involve removing or redistributing the pressure-sensitive areas of the body. Knox et al, in a study of the effects of different turn intervals on healthy individuals came up with a 2-hour repositioning schedule as the minimum requirement. Turning the individual thus serves two purposes. It relieves the pressure that caused the sore and may prevent the start of the sore. Secondly, using foam pads or any form of support surface (special mattresses, seat cushions etc) can also reduce or relieve pressure. Other suggestions include avoiding lying on your hip bone directly, use of a pillow under one side, thus allowing the weight to be placed on the fleshy part of your buttocks or putting a pillow between knees or ankles etc.

Medical personnel need be informed immediately of either suspicion of sores or actual sores. Once pressure sores develop, try not to lie on them. These sores must be kept clean and free of dead tissue. One suggestion is to use a saline solution, which removes extra fluid and loose material around the sore. These sores need to be kept covered. Moist gauze dressing or a hydrocolloid dressing (made of a gel that molds to the pressure sore) is advisable. In fact, dressings are a major component in management of a pressure sore, with maintenance of a moist wound environment being the primary goal of treatment. There are over 300 different dressings marketed for pressure-ulcer care.

Because dead tissue in the sore can interfere with healing and cause infection, the tissue needs to be removed from the sore. Again, check with the treating physician for the method to be used. Choices to be used include: rinsing the sore every time you change the bandage; use of special dressings that help your body dissolve the dead tissue; allowing wet gauze bandages to dry, which results in the dead tissue sticking to the gauze and being removed when the gauze is lifted.

Nutrition will play an important part in helping the body heal the pressure sores. Proper nutrition maintains the body in proper nitrogen balance, which increases wound healing. This is especially true in older individuals who are malnourished or lost weight recently.

Pressure sores that do not heal can spread infection to the rest of the body. The signs to look for include: thick yellow or green pus; bad smell from the sore; swelling around the sore; warmth and tenderness around the sore.

Typical indications that the infection may have spread would include: fever, mental confusion, rapid heartbeat and weakness.

The most important step to prevent pressure sores is to avoid prolonged pressure on one part of your body, especially the pressure points mentioned previously.
It's also important to keep your skin healthy. Keep your skin clean and dry. Use a mild soap (like Dove, Basis or Oil of Olay) and warm (not hot) water. Apply moisturizers so your skin doesn't get too dry. If you must spend a lot of time in bed or in a wheelchair, check your whole body every day for spots, color changes or other signs of sores. Pay special attention to the pressure points where sores are most likely to occur.
For more information about pressure sores, contact:

AHRQ Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907
Phone: 800-358-9295

References for this article
Thomas DR, Goode PS, Tarquine PH, Allman RM.. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc. 1996; 44:1435-1440

Knox DM, Anderson PS. Effects of different turn intervals on skin of healthy older individuals. Adv Wound Care. 1994; 7:48-56.

Agency for Healthcare Research and Quality. Clinical practice guidelines online. Available at:


Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated March 4, 2009

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