Definition

By Mayo Clinic Staff

Bedsore

Bedsores also called pressure sores or pressure ulcers are

injuries to skin and underlying tissue resulting from prolonged
pressure on the skin. Bedsores most often develop on skin that covers
bony areas of the body, such as the heels, ankles, hips and tailbone.

People most at risk of bedsores are those with a medical condition

that limits their ability to change positions, requires them to use a
wheelchair or confines them to a bed for a long time.

Bedsores can develop quickly and are often difficult to treat. Several
things can help prevent some bedsores and help with healing.
 Symptoms
By Mayo Clinic Staff

Bedsore

Bedsores fall into one of four stages based on their severity. The
National Pressure Ulcer Advisory Panel, a professional organization
that promotes the prevention and treatment of pressure ulcers, defines
each stage as follows:

Stage I
The beginning stage of a pressure sore has the following
characteristics:

The skin is not broken.

The skin appears red on people with lighter skin color, and the skin
doesn't briefly lighten (blanch) when touched.

On people with darker skin, the skin may show discoloration, and it
doesn't blanch when touched.

The site may be tender, painful, firm, soft, warm or cool compared with
the surrounding skin.

Stage II
At stage II:

The outer layer of skin (epidermis) and part of the underlying layer of
skin (dermis) is damaged or lost.
The wound may be shallow and pinkish or red.

The wound may look like a fluid-filled blister or a ruptured blister.

Stage III
At stage III, the ulcer is a deep wound:

The loss of skin usually exposes some fat.

The ulcer looks crater-like.

The bottom of the wound may have some yellowish dead tissue.

The damage may extend beyond the primary wound below layers of
healthy skin.

Stage IV
A stage IV ulcer shows large-scale loss of tissue:

The wound may expose muscle, bone or tendons.

The bottom of the wound likely contains dead tissue that's yellowish or
dark and crusty.

The damage often extends beyond the primary wound below layers of
healthy skin.

Unstageable
A pressure ulcer is considered unstageable if its surface is covered
with yellow, brown, black or dead tissue. Its not possible to see how
deep the wound is.

Deep tissue injury

A deep tissue injury may have the following characteristics:

The skin is purple or maroon but the skin is not broken.

A blood-filled blister is present.

The area is painful, firm or mushy.

The area is warm or cool compared with the surrounding skin.

In people with darker skin, a shiny patch or a change in skin tone may
develop.
Common sites of pressure sores
For people who use a wheelchair, pressure sores often occur on skin
over the following sites:

Tailbone or buttocks
Shoulder blades and spine

Backs of arms and legs where they rest against the chair

For people who are confined to a bed, common sites include the
following:

Back or sides of the head

Rim of the ears

Shoulders or shoulder blades

Hip, lower back or tailbone

Heels, ankles and skin behind the knees

When to see a doctor

If you notice early signs or symptoms of a pressure ulcer, change your
position to relieve the pressure on the area. If you don't see
improvement in 24 to 48 hours, contact your doctor. Seek immediate
medical care if you show signs of infection, such as fever, drainage or
a foul odor from a sore, or increased heat and redness in the
surrounding skin.

Causes
By Mayo Clinic Staff

Bedsores are caused by pressure against the skin that limits blood
flow to the skin and nearby tissues. Other factors related to limited
mobility can make the skin vulnerable to damage and contribute to the
development of pressure sores. Three primary contributing factors are:

Sustained pressure. When your skin and the underlying tissues

are trapped between bone and a surface such as a wheelchair or a
 bed, the pressure may be greater than the pressure of the blood
flowing in the tiny vessels (capillaries) that deliver oxygen and other
nutrients to tissues. Without these essential nutrients, skin cells
and tissues are damaged and may eventually die.

This kind of pressure tends to happen in areas that aren't well-

padded with muscle or fat and that lie over a bone, such as your
spine, tailbone, shoulder blades, hips, heels and elbows.

Friction. Friction is the resistance to motion. It may occur when

the skin is dragged across a surface, such as when you change
position or a care provider moves you. The friction may be even
greater if the skin is moist. Friction may make fragile skin more
vulnerable to injury.

Shear. Shear occurs when two surfaces move in the opposite direction.
For example, when a hospital bed is elevated at the head, you can slide
down in bed. As the tailbone moves down, the skin over the bone may
stay in place essentially pulling in the opposite direction. This
motion may injure tissue and blood vessels, making the site more
vulnerable to damage from sustained pressure.

Risk factors
By Mayo Clinic Staff

People are at risk of developing pressure sores if they have difficulty

moving and are unable to easily change position while seated or in
bed. Immobility may be due to:

Generally poor health or weakness

Paralysis

Injury or illness that requires bed rest or wheelchair use

Recovery after surgery

Sedation

Coma
Other factors that increase the risk of pressure sores include:

Age. The skin of older adults is generally more fragile, thinner,

less elastic and drier than the skin of younger adults. Also, older
adults usually produce new skin cells more slowly. These factors
make skin vulnerable to damage.
Lack of sensory perception. Spinal cord injuries, neurological
disorders and other conditions can result in a loss of sensation. An
inability to feel pain or discomfort can result in not being aware of
bedsores or the need to change position.

Weight loss. Weight loss is common during prolonged illnesses,

and muscle atrophy and wasting are common in people with
paralysis. The loss of fat and muscle results in less cushioning
between bones and a bed or a wheelchair.

Poor nutrition and hydration. People need enough fluids, calories,

protein, vitamins and minerals in their daily diet to maintain healthy
skin and prevent the breakdown of tissues.

Excess moisture or dryness. Skin that is moist from sweat or lack

of bladder control is more likely to be injured and increases the
friction between the skin and clothing or bedding. Very dry skin
increases friction as well.

Bowel incontinence. Bacteria from fecal matter can cause

serious local infections and lead to life-threatening infections
affecting the whole body.

Medical conditions affecting blood flow. Health problems that can

affect blood flow, such as diabetes and vascular disease, increase
the risk of tissue damage.

Smoking. Smoking reduces blood flow and limits the amount of

oxygen in the blood. Smokers tend to develop more-severe wounds,
and their wounds heal more slowly.

Limited alertness. People whose mental awareness is lessened

by disease, trauma or medications may be unable to take the
actions needed to prevent or care for pressure sores.
 Muscle spasms. People who have frequent muscle spasms or
other involuntary muscle movement may be at increased risk of
pressure sores from frequent friction and shearing.

Complications
By Mayo Clinic Staff

Complications of pressure ulcers include:

Sepsis. Sepsis occurs when bacteria enter the bloodstream

through broken skin and spread throughout the body. It's a rapidly
progressing, life-threatening condition that can cause organ failure.
Cellulitis. Cellulitis is an infection of the skin and connected soft
tissues. It can cause severe pain, redness and swelling. People with
nerve damage often do not feel pain with this condition. Cellulitis
can lead to life-threatening complications.

Bone and joint infections. An infection from a pressure sore can

burrow into joints and bones. Joint infections (septic arthritis) can
damage cartilage and tissue. Bone infections (osteomyelitis) may
reduce the function of joints and limbs. Such infections can lead to
life-threatening complications.

Cancer. Another complication is the development of a type of

squamous cell carcinoma that develops in chronic, nonhealing
wounds (Marjolin ulcer). This type of cancer is aggressive and
usually requires surgery.

Tests and diagnosis

By Mayo Clinic Staff

Evaluating a bedsore
To evaluate a bedsore, your doctor will:
 Determine the size and depth of the ulcer
Check for bleeding, fluids or debris in the wound that can indicate
severe infection

Try to detect odors indicating an infection or dead tissue

Check the area around the wound for signs of spreading tissue damage
or infection

Check for other pressure sores on the body

Questions from the doctor

When did the pressure sore first appear?
What is the degree of pain?

Have you had pressure sores in the past?

How were they managed, and what was the outcome of treatment?

What kind of care assistance is available to you?

What is your routine for changing positions?

What medical conditions have you been diagnosed with, and what is
your current treatment?

What is your normal daily diet?

How much water and other fluids do you drink each day?

Tests
Your doctor may order the following tests:

Blood tests to check your health

Tissue cultures to diagnose a bacterial or fungal infection in a wound
that doesn't heal with treatment or is already at stage IV

Tissue cultures to check for cancerous tissue in a chronic, nonhealing

wound
Treatments and drugs
By Mayo Clinic Staff

Stage I and II bedsores usually heal within several weeks to months with
conservative care of the wound and ongoing, appropriate general care. Stage
III and IV bedsores are more difficult to treat.

Treatment team
Addressing the many aspects of wound care usually requires a
multidisciplinary approach. Members of your care team may include:

A primary care physician who oversees the treatment plan

A physician specializing in wound care

Nurses or medical assistants who provide both care and education for
managing wounds

A social worker who helps you or your family access appropriate

resources and addresses emotional concerns related to long-term
recovery

A physical therapist who helps with improving mobility

A dietitian who monitors your nutritional needs and recommends an

appropriate diet

A neurosurgeon, orthopedic surgeon or plastic surgeon, depending on

whether you need surgery and what type

Reducing pressure
The first step in treating a bedsore is reducing the pressure that
caused it. Strategies include the following:

Repositioning. If you have a pressure sore, you need to be

repositioned regularly and placed in correct positions. If you use a
wheelchair, try shifting your weight every 15 minutes or so. Ask for
help with repositioning every hour. If you're confined to a bed,
change positions every two hours.
 If you have enough upper body strength, try repositioning yourself
using a device such as a trapeze bar. Caregivers can use bed linens
to help lift and reposition you. This can reduce friction and shearing.

Using support surfaces. Use a mattress, bed and special cushions that
help you lie in an appropriate position, relieve pressure on any sores and
protect vulnerable skin. If you are in a wheelchair, use a cushion. Styles
include foam, air filled and water filled. Select one that suits your
condition, body type and mobility.

Cleaning and dressing wounds

Care that helps with healing of the wound includes the following:

Cleaning. It's essential to keep wounds clean to prevent infection. If

the affected skin is not broken (a stage I wound), gently wash it with
water and mild soap and pat dry. Clean open sores with a saltwater
(saline) solution each time the dressing is changed.
Applying dressings. A dressing promotes healing by keeping a
wound moist, creating a barrier against infection and keeping the
surrounding skin dry. Dressing choices include films, gauzes, gels,
foams and treated coverings. A combination of dressings may be
used.

Your doctor selects a dressing based on a number of factors, such

as the size and severity of the wound, the amount of discharge, and
the ease of placing and removing the dressing.

Removing damaged tissue

To heal properly, wounds need to be free of damaged, dead or infected
tissue. Removing this tissue (debridement) is accomplished with a
number of methods, depending on the severity of the wound, your
overall condition and the treatment goals.

Surgical debridement involves cutting away dead tissue.

Mechanical debridement loosens and removes wound debris. This may
be done with a pressurized irrigation device, low-frequency mist
ultrasound or specialized dressings.
 Autolytic debridement enhances the body's natural process of using
enzymes to break down dead tissue. This method may be used on smaller,
uninfected wounds and involves special dressings to keep the wound
moist and clean.

Enzymatic debridement involves applying chemical enzymes and

appropriate dressings to break down dead tissue.

Other interventions
Other interventions that may be used are:

Pain management. Pressure ulcers can be painful. Nonsteroidal anti-

inflammatory drugs such as ibuprofen (Motrin IB, Advil, others) and
naproxen (Aleve, others) may reduce pain. These may be very helpful
before or after repositioning, debridement procedures and dressing
changes. Topical pain medications also may be used during debridement
and dressing changes.
Antibiotics. Infected pressure sores that aren't responding to other
interventions may be treated with topical or oral antibiotics.

A healthy diet. To promote wound healing, your doctor or dietitian may

recommend an increase in calories and fluids, a high-protein diet, and an
increase in foods rich in vitamins and minerals. You may be advised to
take dietary supplements, such as vitamin C and zinc.

Management of incontinence. Urinary or bowel incontinence may cause

excess moisture and bacteria on the skin, increasing the risk of infection.
Managing incontinence may help improve healing. Strategies include
frequently scheduled help with urinating, frequent diaper changes,
protective lotions on healthy skin, and urinary catheters or rectal tubes.

Muscle spasm relief. Spasm-related friction or shearing can cause or

worsen bedsores. Muscle relaxants such as diazepam (Valium),
tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen (Gablofen,
Lioresal) may inhibit muscle spasms and help sores heal.

Negative pressure therapy (vacuum-assisted closure, or VAC). This

therapy uses a device that applies suction to a clean wound. It may help
healing in some types of pressure sores.
Surgery
A pressure sore that fails to heal may require surgery. 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 cancer.

If you need surgery, the type of procedure depends mainly on the

location of the wound and whether it has scar tissue from a previous
operation. In general, most pressure sores are repaired using a pad of
your muscle, skin or other tissue to cover the wound and cushion the
affected bone (flap reconstruction).

Coping and support

By Mayo Clinic Staff

Treating and preventing pressure sores is demanding on you, your

family members and caregivers. Issues that may need to be addressed
by your doctor, the nursing staff and a social worker include the
following:

Community services. A social worker can help identify

community groups that provide services, education and support for
people dealing with long-term caregiving or terminal illnesses.
End-of-life care. When someone is approaching death, physicians
and nurses specializing in end-of-life care (palliative care) can help
a patient and his or her family determine treatment goals. At this
time, goals may include managing pain and providing comfort.

Residential care. People with limited mobility who live in

residential or nursing care facilities are at increased risk of
developing pressure sores. Family and friends of people living in
these facilities can be advocates for the residents and work with
nursing staff to ensure proper preventive care.
Prevention
By Mayo Clinic Staff

Bedsores are easier to prevent than to treat, but that doesn't mean the
process is easy or uncomplicated. And wounds may still develop with
consistent, appropriate preventive care.

Your doctor and other members of the care team can help develop a
good strategy, whether it's personal care with at-home assistance,
professional care in a hospital or some other situation.

Position changes are key to preventing pressure sores. These changes

need to be frequent, repositioning needs to avoid stress on the skin,
and body positions need to minimize pressure on vulnerable areas.
Other strategies include taking good care of your skin, maintaining
good nutrition, quitting smoking and exercising daily.

Repositioning in a wheelchair
Consider the following recommendations related to repositioning in a
wheelchair:

Shift your weight frequently. If you use a wheelchair, try shifting your
weight about every 15 minutes. Ask for help with repositioning about once
an hour.
Lift yourself, if possible. If you have enough upper body strength, do
wheelchair pushups raising your body off the seat by pushing on the
arms of the chair.

Look into a specialty wheelchair. Some wheelchairs allow you to tilt

them, which can relieve pressure.

Select a cushion that relieves pressure. Use cushions to relieve

pressure and help ensure your body is well-positioned in the chair. Various
cushions are available, such as foam, gel, water filled and air filled. A
physical therapist can advise you on how to place them and their role in
regular repositioning.

Repositioning in a bed
Consider the following recommendations when repositioning in a bed:
 Reposition yourself frequently. Change your body position every two
hours.
Look into devices to help you reposition. If you have enough upper body
strength, try repositioning yourself using a device such as a trapeze bar.
Caregivers can use bed linens to help lift and reposition you. This can
reduce friction and shearing.

Try a specialized mattress. Use special cushions, a foam mattress pad,

an air-filled mattress or a water-filled mattress to help with positioning,
relieving pressure and protecting vulnerable areas. Your doctor or other
care team members can recommend an appropriate mattress or surface.

Adjust the elevation of your bed. If your hospital bed can be elevated at
the head, raise it no more than 30 degrees. This helps prevent shearing.

Use cushions to protect bony areas. Protect bony areas with proper
positioning and cushioning. Rather than lying directly on a hip, lie at an
angle with cushions supporting the back or front. You can also use
cushions to relieve pressure against and between the knees and ankles.
You can cushion or ''float'' your heels with cushions below the calves.

Skin care
Protecting and monitoring the condition of your skin is important for
preventing pressure sores and identifying stage I sores early so that
you can treat them before they worsen.

Clean the affected skin. Clean the skin with mild soap and warm water
or a no-rinse cleanser. Gently pat dry.
Protect the skin. Use talcum powder to protect skin vulnerable to
excess moisture. Apply lotion to dry skin. Change bedding and clothing
frequently. Watch for buttons on the clothing and wrinkles in the bedding
that irritate the skin.

Inspect the skin daily. Inspect the skin daily to identify vulnerable
areas or early signs of pressure sores. You will probably need the help of a
care provider to do a thorough skin inspection. If you have enough
mobility, you may be able to do this with the help of a mirror.

Manage incontinence to keep the skin dry. If you have urinary or bowel
incontinence, take steps to prevent exposing the skin to moisture and
bacteria. Your care may include frequently scheduled help with urinating,
 frequent diaper changes, protective lotions on healthy skin, or urinary
catheters or rectal tubes.

Nutrition
Your doctor, a dietitian or other members of the care team can
recommend nutritional changes to help improve the health of your
skin.

Choose a healthy diet. You may need to increase the amount of

calories, protein, vitamins and minerals in your diet. You may be advised
to take dietary supplements, such as vitamin C and zinc.
Drink enough to keep the skin hydrated. Good hydration is important for
maintaining healthy skin. Your care team can advise you on how much to
drink and signs of poor hydration. These include decreased urine output,
darker urine, dry or sticky mouth, thirst, dry skin, and constipation.

Ask for help if eating is difficult. If you have limited mobility or

significant weakness, you may need help with eating in order to get
adequate nutrition.

Other strategies
Other important strategies that can help decrease the risk of bedsores
include the following:

Quit smoking. If you smoke, quit. Talk to your doctor if you need help.
Stay active. Limited mobility is a key factor in causing pressure sores.
Daily exercise matched to your abilities can help maintain healthy skin. A
physical therapist can recommend an appropriate exercise program that
improves blood flow, builds up vital muscle tissue, stimulates appetite and
strengthens the body.