Pressure Injuries aka Bedsores aka Decubitus Ulcers are one of the more common types of wounds a wound care nurse is bound to encounter at a nursing home.
This type of wound is common among bedridden, immobile, or limited mobility, semi-conscious or unconscious patients who have difficulty sensing pain. Frequently these patients reside at nursing facilities.
As can be expected, bedsores are common in frail, older adults but with proper knowledge and care, this type of wound can be prevented.
What are Bedsores?
The best way to understand how to treat bedsores is to know what causes them, the pathophysiology behind them. Bedsores are defined as pressure ulcers that occur in areas of the skin that are subject to a certain amount of pressure, commonly on bony prominences.
This can be brought about by sitting in a wheelchair, lying in bed, or wearing a cast for a prolonged period of time. When an immobile or bedridden patient isn’t moved, turned, or repositioned correctly as often as they should, bedsores can develop.
Bedsores also go by different names. They may also be referred to as pressure injuries, pressure ulcers, or decubitus ulcers, among others.
It’s been said that people with poor circulation, diabetes, and poor nutrition are at a higher risk of developing this type of wound.
Though we’ve defined how bedsores come about, it’s important to understand what causes a person to develop one.
Bedsores are brought about primarily by the restriction of blood supply to the skin for more than 2 to 3 hours. What causes restriction of blood flow you may ask? The bony prominence collapses the blood supply to the skin, hence it’s important to offload every 2-3 hours, meaning remove pressure from the area so the bony prominence isn’t collapsing the blood supply.
If the pressure is relieved, the skin becomes red and painful as blood flow to the area is decreased, eventually, the skin breaks open leading to a pressure ulcer.
Depending on their severity, bedsores can get deep and extend into the muscle or even worse, into the bone. They also heal very slowly and can take days, months, or even years to fully get healed. Some may even require surgery to help with the healing process.
But don’t get fooled, once a pressure injury develops and with all the hard work we get it to heal, the tensile strength will never be as good as new and always prone to breakdown, again and again! So it’s important to avoid it from the start!
Some of the areas usually affected by bedsores are the buttocks (specifically the tailbone and hips), the back of the head, the sides of the knees, the shoulder blades, along with the heels and lateral foot.
Bedsores are usually categorized into 4 stages depending on their severity.
Stage 1 is when they begin to turn red and feel warm to the touch. Patients may also complain of itching and burning sensation.
Stage 2 is when the affected area begins to have an open blister, scrape, or sore. Superficial skin breakdown is what you’ll see. Around this time, patients may begin complaining of severe pain and the wound may also appear discolored. Regardless it’s superficial and doesn’t really have depth. Kind of like a skin tear but in a bony prominence.
By Stage 3, the wound may develop a crater-like appearance because of the damage under the skin’s surface. There’s depth to the wound and it may have what we call slough, necrotic slimy tissue that needs to be removed before it can heal.
At Stage 4, which is considered the most severe, the affected area may already be severely damaged with a large wound noticeably visible. By this time, the muscles, bones, tendons, and joints are also involved and the patient could be at risk of infection.
DTI aka Deep Tissue Injury is maroon discoloration of the skin on a bony prominence. Of note, the skin is intact. I often describe this as a deep bruise. This often breaks down to stage four.
Unstageable is when there is so much necrotic tissue or eschar that the depth of the wound cannot be seen.
After the necrotic tissue or eschars removed by sharp debridement, unstageable wounds often turn into stage four or stage three.
Diagnosis and Treatment
Bedsores are diagnosed by thoroughly inspecting the skin or the affected area often by the wound care nurse. Depending on the severity, different treatment options are available which may include the following:
Removing pressure on the affected area
Ensuring proper patient nutrition
Debridement (removal of dead or infected tissue)
Regularly cleaning the wound and applying the correct ointments
Covering the wound with a protective gauze
Skin grafts (transplanting of healthy skin into the affected area)
Taking antibiotics if wounds are infected
Negative pressure wound therapy
Most importantly, if the inciting factor, the pressure is not relieved, regardless of all efforts, the wound will not heal. Pressure must be relieved.
It’s critical that proper treatment is provided before the wound becomes more severe. If pressure ulcers are left untreated with continued pressure, bedsores can lead to major complications. If the infection spreads throughout the body, patients may become septic, systemic illness.
Pressure ulcers are usually avoidable as long as proper care and attention are rendered regularly to the affected area.
One of the ways to prevent bedsores from developing is to turn or reposition the patient every 2 to 3 hours. Getting patients to change positions every 15 minutes in a wheelchair is also advisable.
To reduce pressure, providing soft padding for the wheelchair can also be an option. Good skin care and nutrition will also help.
As with many health conditions, prevention is always better than cure, and pressure ulcers definitely fall under that category. By turning and changing an immobile patient’s position every so often which is the protocol at nursing facilities or nursing homes, you can keep bedsores from developing and in the process, prevent infection and further complications.
Enroll in our Wound Care Certification course by SNF Wound Care for a comprehensive review on Pressure Ulcers which will earn nurses nationwide with Wound Certification by WSOC (Wound, Skin, Ostomy Certification) and earn 30 CEU for license renewal for RN & LPN/LVN.