Pressure Sores

Risk factors for pressure sores include the following:

Pressure sores occur most frequently in older adults because their skin may be thinner and may heal more slowly. The sores often develop in people after they have been hospitalized for a different medical problem that limits their ability to move or shift around.

Pressure sores can occur in people of any age who are confined to bed or a chair, or who are unable to reposition themselves. People who have nerve damage or paralysis have a higher risk of developing pressure sores. They can also develop in children who have severe neurologic impairments that make them less able to move such as spina bifida Spina Bifida Neural tube defects are a certain type of birth defect of the brain, spine, and/or spinal cord. Neural tube defects can result in nerve damage, learning disabilities, paralysis, and death. The... read more , cerebral palsy Cerebral Palsy (CP) Cerebral palsy refers to a group of conditions that involve difficulty moving and muscle stiffness (spasticity). It results from brain malformations that occur before birth as the brain is developing... read more , and spinal cord injury Spinal Cord Injury in Children A spinal cord injury is damage to the bundle of cells and nerves that carry incoming and outgoing messages between the brain and the rest of the body. Most spinal cord injuries in children younger... read more .

Inadequate nutrition Undernutrition Undernutrition is a deficiency of calories or of one or more essential nutrients. Undernutrition may develop because people cannot obtain or prepare food, have a disorder that makes eating or... read more increases the risk of developing pressure sores and slows the healing process of sores that do develop. Undernourished people may not have enough body fat to cushion the tissue. Also, the skin heals poorly if people are undernourished, particularly if they are deficient in protein, vitamin C, or zinc.

Causes that contribute to the development of pressure sores include

For most people, pressure sores cause some pain and itching. However, in people whose senses are dulled, even severe sores may be painless.

Pressure sores are categorized into four stages (1 to 4) according to the severity of soft-tissue damage. Pressure sores do not always progress from mild to severe stages. Sometimes the first noticeable sign is a stage 3 or 4 sore.

Stage 1: On light skin, the skin is red or pink. On dark skin, there may be no changes in skin color.

The skin may also be warmer, cooler, firmer, softer, or more tender than nearby skin that is not injured by pressure. At this stage, an actual ulcer is not yet present (the skin is not broken).

Stage 2: The pressure sore is shallow with a pink to red base. Some skin may be lost, and blisters may develop. Deeper tissues beneath the sore cannot be seen.

Stage 3: The skin over the sore is worn away. The sore sometimes goes down to the layer of fat, but deeper structures beneath the sore, such as muscles and bones, cannot be seen.

Stage 4: The skin is worn away all the way through, making the deep structures beneath the sore, such as muscles, tendons, and bones, visible.

Unstageable: Sometimes doctors cannot determine what stage a pressure sore is. For example, pressure sores that are covered with debris or a thick, crusty surface (eschar) cannot be staged unless the debris or eschar is removed.

Deep-tissue pressure injury: These injuries are purple- to maroon-colored areas of broken or unbroken skin or blood-filled blisters that are caused by damage to the underlying soft tissues. The area may feel firmer, mushier, warmer, or cooler than surrounding tissue.

Medical device–related pressure injury: These injuries result from the use of devices designed and applied for treatment purposes. Long-term use of medical devices, especially if they are poorly placed or ill-fitting, can cause injury to skin or mucous membranes (the moist surfaces or inner linings of some parts of the body).

For example, masks or tubing used for people who need oxygen can cause pressure sores on the bridge of the nose, the ears, the back of the head, or wherever the mask or tubing applies pressure. Poorly fitting dentures or an improperly secured endotracheal tube can cause pressure sores inside the mouth. Injuries typically conform to the pattern or shape of the device.

Doctors are usually able to determine a stage for medical device–related pressure injuries to the skin but not to the mucous membranes.

Bacterial infection is the most common complication of pressure sores. If pressure sores become infected, they may have an unpleasant odor. Pus may be visible in or around the sore. The area around the sore may become red or feel warm, and pain may worsen if the infection spreads to the surrounding skin and tissues beneath the skin. Some people may have a fever. Infection delays healing of shallow sores and can be life threatening in deeper sores.

Infection in pressure sores that do not heal may cause cellulitis Cellulitis Cellulitis is a spreading bacterial infection of the skin and the tissues immediately beneath the skin. This infection is most often caused by streptococci or staphylococci. Redness, pain, and... read more and sinus tracts to form. Cellulitis is a spreading bacterial infection of the skin and the tissues immediately beneath the skin. Sinus tracts are passages that connect the infected area of the skin surface or the sore to other structures, such as those deep in the body. For example, a sinus tract from a pressure sore near the pelvis can connect to the bowel (this abnormal connection is called a fistula). Infection can even penetrate the bone (osteomyelitis Osteomyelitis Osteomyelitis is a bone infection usually caused by bacteria, mycobacteria, or fungi. Bacteria, mycobacteria, or fungi can infect bones by spreading through the bloodstream or, more often, by... read more ) or a joint (infectious arthritis Infectious Arthritis Infectious arthritis is infection in the fluid and tissues of a joint usually caused by bacteria but occasionally by viruses or fungi. Bacteria, viruses, or fungi may spread through the bloodstream... read more ), or it can rapidly spread to destroy muscle and other deep tissues (necrotizing fasciitis Necrotizing Skin Infections Necrotizing skin infections, including necrotizing cellulitis and necrotizing fasciitis, are severe forms of cellulitis. These infections cause infected skin and tissues to die (necrosis). The... read more ).

In some severe cases, infection can spread into the bloodstream (bacteremia Bacteremia Bacteremia is the presence of bacteria in the bloodstream. Bacteremia may result from ordinary activities (such as vigorous toothbrushing), dental or medical procedures, or from infections ... read more ), causing fever or shaking chills, and later can spread to the brain (meningitis Acute Bacterial Meningitis Acute bacterial meningitis is rapidly developing inflammation of the layers of tissue that cover the brain and spinal cord (meninges) and of the fluid-filled space between the meninges (subarachnoid... read more ) and heart (endocarditis Infective Endocarditis Infective endocarditis is an infection of the lining of the heart (endocardium) and usually also of the heart valves. Infective endocarditis occurs when bacteria enter the bloodstream and travel... read more ).

Doctors can usually diagnose pressure sores by doing a physical examination and noting the appearance and location of the sores.

Because the depth and severity of pressure sores are difficult to determine, doctors or specially trained health care professionals stage and photograph pressure sores to monitor how they progress or heal. Doctors use specific criteria to determine how a pressure sore is healing.

Doctors also assess people for their nutrition status by examining them and asking about their food intake and weight changes.

People with pressure sores, especially those with stage 3 or 4 sores, sometimes have blood tests. Sometimes a blood sample is cultured to see whether infection has spread to the bloodstream.

People who are undernourished are evaluated further Testing Undernutrition is a deficiency of calories or of one or more essential nutrients. Undernutrition may develop because people cannot obtain or prepare food, have a disorder that makes eating or... read more .

When pressure sores do not heal, doctors often suspect a complication such as an infection. If osteomyelitis is suspected, doctors do blood tests and often the imaging test magnetic resonance imaging Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI) is a type of medical imaging that uses a strong magnetic field and very high frequency radio waves to produce highly detailed images. During an MRI, a computer... read more (MRI). To confirm osteomyelitis, doctors may need to take a small sample (biopsy) of bone to see if bacteria grow from it (culture).

Treating a pressure sore is much more difficult than preventing one.

The main goals of treatment are to relieve pressure on the sores, clean and dress the wounds appropriately, control infection, and provide adequate nutrition. Sometimes surgery is needed to close large wounds.

The prognosis for early-stage pressure sores is excellent if people have received timely, appropriate treatment, but healing typically requires weeks. After 6 months of treatment, more than 70% of stage 2 pressure sores, 50% of stage 3 pressure sores, and 30% of stage 4 pressure sores resolve.

Pressure sores often develop in people who are receiving inadequate care, have disorders that impair wound healing (such as diabetes or undernutrition), or both. Without continual meticulous care of the sores and treatment of other disorders and complications, long-term prognosis is poor, even if pressure sores have healed.

Prevention is the best strategy for dealing with pressure sores. In most cases, pressure sores can be prevented by meticulous attention from all caregivers, including nurses, nurses’ aides, and family members.

Frequent repositioning is the best way to avoid pressure sores. People who cannot move themselves should be repositioned frequently. For example, people who are confined to bed should be repositioned at least every 1 to 2 hours. People who are placed in a chair should be repositioned every hour. If they are capable, they should be encouraged to change position on their own every 15 minutes.

Every day, caregivers should closely inspect the skin to look for early signs of redness or discoloration. Any sign of redness or discoloration at pressure areas is a signal that the person needs to be repositioned and kept from lying or sitting on the discolored area until it returns to normal.

Skin care is vital to preventing pressure sores. The skin must be kept clean and dry because moisture increases the risk of developing pressure sores. Dry skin is less likely to stick to fabrics and cause friction or traction. After cleaning, the skin should be dried by gentle patting (avoiding rubbing the skin). The use of thick creams that act as a barrier to protect the underlying skin from moisture may help prevent sores. For people confined to bed, sheets and clothing should be changed frequently to make sure they are clean and dry. Cornstarch may allow microorganisms to grow and should not be used, but plain talc can be used in areas subject to friction.

Bony areas (such as heels and elbows) can be protected with soft materials, such as foam wedges and heel protectors. Protective padding, pillows, or sheepskin can be used to separate body surfaces. Special beds, mattresses, and seat cushions can reduce pressure and offer extra relief to people who use a wheelchair or are confined to bed. A doctor or nurse can recommend the most appropriate mattress surface or seat cushion. It is important to remember that these devices do not eliminate pressure completely and are not substitutes for frequent repositioning.

Movement is an important part of pressure sore prevention. People who have difficulty moving or who are immobilized are at risk of developing pressure sores, so activity should be encouraged. Medications that induce sleep (sedatives Misuse of Antianxiety Medications and Sedatives Antianxiety and sedative medications are prescription drugs used to relieve anxiety and/or help with sleep, but their use can result in dependency and a substance use disorder. Using prescription... read more ) should be reduced or avoided because people who are sleepy are less likely to change position.