Bed Sores -- The Basics

---

 "Bed sores" owe their name to the ovservation that patiens who were bedridden and not properly re-positioned, would develop ulcerations or sores on their skin, typically over bony prominences.  These bed sores, which result from prolonged pressure, are also known as decubitus ulcers, pressure sores, and pressure ulcers. 

Bed sores are a localized area of tissue injury that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.  The external surface may be a mattress, a chair or wheelchair, or even other parts of the body.  The soft tissues of the body, such as skin and muscle, depend upon blood vessels to carry nutrients to the tissues, and to remove waste products.  Bed sores result when prolonged pressure prevents sufficient blood flow to supply the tissues with nutrients.  The resulting bed sore represents the death of the involved soft tissues. 

Bed sores can result from one period of sustained pressure; however, most bed sores probably occur as a result of repeated incidents of blood flow interruption without adequate time for recovery.  In fact, low pressure endured for long periods of time is believed to be more significant in producing pressure ulcers than higher pressure for shorter durations.

It is important to note that bed sores do not always result from being in bed as the name would imply.  Some of the most severe bed sores can also result from sitting for a prolonged period of time. Thus, the location of the bed sores can depend upon the position of the patient.  For individuals who are bed-bound, the sores are most likely to form on or around the heels, the hip-bone, and the lower back or tailbone.  Pressure ulcers may also develop in a variety of other areas, including the spine, ankles, knees shoulders, and head, depending upon the position of the patient. 

Pressure sores are more likely to develop persons who are at higher risk due to one or more risk factors.  A number of risk factors have been identified which put individuals at higher risk.  Once a person is identified as being at increased risk for pressure sores, measures should be undertaken to reduce or eliminate those risks.  Thus, healthcare providers must be aware of these risk factors when caring for patients in order to prevent the unnecessary development of pressure sores.  While risk factors may vary depending upon the particular circumstances, the following represents a list of the most common:

1.  Confinement to bed, chair, or wheelchair.   Persons confined to beds, chairs, or wheelchairs who are unable to move themselves, can develop pressure-induced injuries in as little as 1-2 hours if the pressure is not relieved;

2.  Inability to change positions without help.  (Eg., an individual in a coma, who is paralyzed, or recovering from a hip fracture or other mobility limitation.) 

3.  Loss of bowel or bladder control.  Sources of moisture on the skin from urine, stool, or perspiration can irritate the skin.

4.  Poor nutrition and/or dehydration.  Bed sores are more likely to form when the skin is not properly nourished.

5.  Decreased mental awareness.  An individual with decreased mental awareness may not have the level of sensory perception or ability to act to prevent the development of pressure-induced injury.  The lack of mental awareness may arise from medications.

Most pressure sores can be prevented, and those which have formed need not necessarily get worse.  Each patient's individual circumstances must be taken into consideration by the caregiver in order to develop a plan of care which will best assure the patient will not unnecessarily suffer from a pressure sore.  The following generally represent some of the precautions which health care providers should, but too often fail to undertake:

1.  An appropriate and thorough and systematic assessment must be made of the patient's risk for developing a pressure sore;

2.  Appropriate periodic reassessment should be made of the patient's risk;

3.  The patient should be bathed appropriately;

4.  The patient's incontinence should be assessed and treated to assure that moisture on the skin does not contribute to the development of a pressure sore;

5.  Appropriate nutrition and hydration must be maintained;

6.  Repositioning of the patient should occur with a frequency to assure that the pressure is adequately relieved;

7.  Use of appropriate support devices should be maintained to relieve pressure from troublesome areas;

8.  Postural alignment, distribution of weight, balance and stability, and pressure relief should be considered when positioning persons in chairs or wheelchairs;

9.  Appropriate lifting devices and techniques should be used to assure that shear and friction related injuries are avoided;

10.  Education should be given to the patient, family, and caregivers on measures to be taken to avoid pressure sores, and appropriate documentation of such measures.

It is essential to remember that every individual is different, and has different risk factors, thus requiring a customized plan of care and diligence in carrying out the plan of care.