What Are Bed Sores (Pressure Ulcers)?

Bed sores are wounds that affect areas of skin and underlying soft tissue that have had pressure put on them for long periods of time. Bed sores might also be referred to as pressure sores, pressure ulcers, pressure injuries, or decubitus ulcers. The sores typically form on bony parts of the body, such as the elbows, knees, heels, and tailbone.

Bed sores can develop when a person remains in the same position for a prolonged period of time, maybe because they have decreased mobility or have been sedated. The pressure injury can also develop if a medical device exerts pressure for an extended time, such as oxygen tubing resting behind someone's ears without sufficient padding.

Pressure injuries are broken down into different stages based on how deep the wound is. The symptoms can range from mild to severe. Prompt treatment is necessary to avoid complications. Fortunately, bed sores are largely preventable with proper vigilance and care.

Symptoms

The symptoms you can experience from a bed sore depend on how many layers of skin and tissue the sore is affecting. At first, a bed sore may make your skin that's covering a bony part of the body look red. When you press on the red, your skin does not get paler but instead remains red.

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Other symptoms of bed sores include a change in the temperature of the skin. The area might feel cooler or warmer than usual. The area might also feel softer or firmer. You might also feel pain.

The affected area might start to blister. The area might also eventually develop an open wound. As this happens, the surrounding skin around can become red and irritated.

As the bed sore worsens, the wound can get deeper and turn into an ulcer. An ulcer is an open hole that resembles a crater. You might even be able to see layers beneath your skin, such as body fat, in the ulcer.

Sometimes bed sores initially appear as purple areas of discoloration. The sores might also be covered in patches of dead skin.

Causes

Bed sores occur when there is too much pressure on your skin for too long. This can occur from consistent pressure or rubbing. The pressure prevents blood from getting to the tissues, leading the tissue to become damaged or die. Pressure injuries can start to develop in as little as two hours.

Risk Factors

You can be at an increased risk for developing pressure injuries if you:

• Have a condition that affects blood flow, like diabetes or peripheral artery disease
• Are an older adult
• Cannot move certain parts of your body without assistance
• Spend long amounts of time in a wheelchair or in bed
• Are malnourished
• Have incontinence of the bladder or bowel
• Have skin that is easily damaged
• Have dementia or another disease that affects your mental state

Diagnosis

Bed sores can be diagnosed through a physical assessment. The person with the wound or their caregiver may be able to identify a wound as a bed sore on their own, but you'd still want to see a healthcare provider to rule out any alternate diagnoses and receive proper treatment instructions.

The healthcare provider evaluating the wound may do the following:

• Measure the length or width of the wound
• Identify the presence of drainage
• Look for tunneling, which is where the wound extends underneath the skin
• Ask questions about how long the wound has been there, how it began, and what previous treatments there has been
• Determine the stage of the wound

Stages of Bed Sores

Pressure sores are usually categorized into one of four stages. The stages are based on the wound's depth:

• Stage 1: The skin is not damaged but is red. When you press on the red area, the skin does not turn white or get paler but instead stays red. The skin may be warm or cool. It might also feel either firm or soft. This is the mildest stage.
• Stage 2: The top and middle layers of skin (the epidermis and dermis) are affected. An open sore or blister develops on the area of skin. The surrounding area may be red or irritated.
• Stage 3: Injuries in this stage are considered "full thickness," meaning they involve the epidermis, dermis, and subcutaneous tissue (the deepest layer of skin). In this stage, an ulcer develops. Because the damage extends to the tissue below the skin, you might be able to see body fat in the ulcer.
• Stage 4: The pressure ulcer has extended so much that the muscle and bone are damaged. The tendons and joints may become damaged, too.

The stages are not necessarily linear, meaning your sore might not start at stage 1, and it might not evolve into a stage 4 wound.

There are also bed sores that are considered unstageable. These sores are covered in yellow, tan, green, or brown dead skin, making it hard to see how deep the sore is. Because it's difficult to know the depth, it cannot be put into one of the four stages.

Another type of pressure sore that does not fit into one of the four stages is a deep tissue injury, which is an injury that develops in the tissue below the skin. The affected area may look dark purple or maroon on the outside of the skin. You may also have a blood-filled blister underneath your skin. A deep tissue injury can become a stage 3 or 4 pressure sore in a short amount of time.

Treatment

Treatment should start as soon as a bed sore starts to develop to prevent a worsening injury. The main part of treatment is keeping as much pressure off the injury as possible. This can be done by repositioning the person every couple hours and by using a padded surface rather than a hard surface.

Treatment should also include keeping the injury clean and preventing excess moisture.

Besides these main pillars of treatment for all bed sores, treatment would otherwise differ based on which stage the bed sore is. For instance, stage 1 or 2 ulcers do not usually need surgical intervention, but stage 3 or 4 wounds may. The surgery might include removal of any dead skin, cleaning of the crater, and filling the crater with healthy tissue.

The location of the bed sore might also impact treatment. If the sore is in a place where urine or feces can contaminate the wound, you may need something to divert your waste away from the area. This might include a catheter, a thin tube that is inserted through your urethra or into your bladder that brings waste out of the body.

Prevention

Thankfully, bed sores can be preventable. One important way to prevent bed sores is to reduce the amount of pressure on any one part of the body so the blood keeps flowing to that area.

If someone is able to move, encourage them to do so frequently. If someone is unable to move at all or unable to move a part of their body, they should be repositioned every two hours. As you are repositioning the person, check for sores or signs of sores, like redness. Some people might need to be repositioned more or less often—check with their healthcare provider to see how frequently you should be doing it.

You can also prevent bed sores by putting supportive surfaces, like a foam, air, or water mattress, over a hard surface.

Making sure the person at risk for bed sores is taking in the right mix of nutrients, as this can also help prevent pressure injuries.

Complications

One common complication for bed sores is infection. Stage 3 and 4 wounds are particularly at risk for infection because the bacteria can more easily spread into exposed bones or joints. It is important to identify and treat infection in any wound stage as the infection has the potential to travel to the bloodstream and causes sepsis, a life-threatening response to an infection.

Wounds use up a lot of your body's energy to heal, which can lead to dehydration and malnutrition. It is important to follow your healthcare provider's recommendations regarding fluid intake and nutrition for wound healing.

A Quick Review

Bed sores are injuries to your skin—and potentially the underlying soft tissue—that develop when there is pressure put on parts of your body for an extended period of time. The pressure prevents blood from properly flowing to the area, which damages the tissue. The sores most often develop at your boniest parts, such as your elbows or tailbone.

There are four stages of bed sores based on how deep the injury goes. Stage 1 is the mildest stage, and you might see reddening of the skin. Other stages involve open injuries to the surface of the skin as well as the tissue below.

A bed sore can develop in as little as two hours. That's why repositioning someone at risk for a bed sore, such as someone with mobility issues, is important in preventing sores. If a bed sore does develop, early identification and treatment are crucial to preventing complications.