Last Updated: April 4, 2015
By Jeannette Franks, PhD
Family members with someone in long-term
care need to be knowledgeable and vigilant about decubitus
ulcers-the dreaded bedsores.
Bedsores, also called pressure sores, pressure ulcers, or
decubitus ulcers, are skin wounds resulting from prolonged pressure
on the skin in contact with a bed or wheelchair. Bedsores are
painful, take a long time to heal, and are often a precursor of
life-threatening complications such as skin and bone
The human body is designed to be in constant movement, even
while we sleep. We constantly shift positions, always unconsciously
readjusting ourselves in bed, at the computer station, watching TV,
or whatever active or inactive pursuit engages us.
How Bedsores Form
Bedsores form in the areas where we have the least padding of
muscle and fat, especially right over a bone. Bedsores on the
tailbone (coccyx), shoulder blades, hips, heals and elbows are the
most common. Total immobility, even for as little as 12 hours, can
Circulation is impeded when blood flow slows or stops in the
compressed area between bone and the surface of a bed or
wheelchair. When the tissue is deprived of oxygen and nutrients,
the skin can die in as little as half a day, although the evidence
may not be obvious for days or even weeks.
When surgery, injury to the spinal cord, or an illness causes
immobility even for less than a day, the pressure of the
immobilized body on certain areas can break down the skin. In bed,
the most dangerous areas are the tailbone or buttocks and the
heels. The toes, ankles, knees, hipbones, shoulders and shoulder
blades, and even the rims of the ears are also at risk.
In a wheelchair, the locations at highest risk are again the
tailbone and buttocks, as well as shoulder blades and the spine,
and the backs of arms and legs where they touch the chair.
Bedsores often start at the hospital. Whether before or after
surgery, many injuries make movement painful or impossible. It only
takes a half a day, immobilized in bed, for a bedsore to start,
especially if the person is already compromised by age, dementia,
poor circulation, thin skin, incontinence,
or nutritional deficits.
Problems such as arthritis or injury that make movement painful
or impossible increase the probability of bedsores. Diabetics and
paraplegics who have no sense of feeling in their feet
are especially at risk.
Two Additional Causes of Bedsores: Friction and Shear
Shear occurs when the skin moves in one direction and the
underlying bone in another direction. Slowly sliding or slumping
down in a bed or chair can cause the skin to stretch and tear.
Transferring from bed to wheelchair or vice versa can also cause
skin tears from shear.
Friction may also cause the skin to degrade. Even though frequent
changes in position are important to prevent bed sores, the
constant movement and rubbing can again break down skin. The
gentlest assistance can still cause a skin wound, especially since
human skin gets thinner and more fragile with age.
Good skin hydration with lotion can be helpful, and of course it
is important to keep all skin clean and dry.
Age is the greatest risk factor for bedsores; the older the
person, the more vulnerable their skin. A gross insult to teenage
skin, such as a huge abrasion and broken bones from skateboarding,
may recover rapidly, even after a week in bed. But for an
immobilized older person, a small skin tear, even from a gentle
transfer from wheelchair to bed, might quickly develop into a
Other risk factors include smoking, lack of pain perception,
urinary or fecal incontinence, malnutrition, dementia, and other
medical conditions such as diabetes.
The Four Stages of Bed Sores
- Stage I
In stage I a persistent area of red skin may itch or hurt. The
spot can feel warm or spongy to the touch; conversely it may feel
hard. In darker skin, the patch may look blue or purple, or appear
flakey or ashen. Stage I wounds will usually disappear promptly if
the pressure is relieved.
- Stage II
In stage II, the skin is already compromised. An open sore that
looks like a blister or abrasion is a red flag. The surrounding
area may be discolored. When treated promptly, these sores can heal
quickly if the person is otherwise in good health and not
experiencing other problems such as diabetes or paralysis.
- Stage III
Stage III bedsores are often extremely painful and difficult to
treat. The pressure ulcer has extended through all the skin layers
down to muscle. The deep, crater-like wound indicates permanently
- Stage IV
Stage IV bedsores, the most serious and advanced stage, destroy
muscle, bone, and even tendons and joints. Stage IV bedsores are
Repositioning the body at least every two hours in bed, or every
30 minutes in a wheelchair, can help prevent bedsores, as can
special beds, pillows, and mattresses. However, this repositioning
can cause its own problems. It is miserable to be awakened every
two hours, especially if you are recovering from illness, surgery,
or an accident. Moving anyone every two hours, or especially every
30 minutes, is an enormous staff challenge for any facility
providing personal care services, particularly in a busy hospital
or nursing home. And people with dementia and/or pain will suffer
and quite reasonably protest.
- Avoid lying directly on the hipbones and support legs correctly
with a foam pad or pillow (never a doughnut-shaped cushion or any
type of rubber pad). Put the support under the legs from the middle
of the calf to the ankle and keep knees and ankles from touching.
It's helpful to have a little tent over the toes, and to use
special heel pads.
- Avoid raising the head more than 30 degrees and use pillows or
foam wedges to help the person to sit up to eat. Expert advice and
assistance is crucial. Do not try to reposition a frail person
- Specially designed mattresses and beds are available. Different
options of foam, air, gel, or water in a bed that can be
automatically or manually readjusted on a regular schedule can work
well. Again, consult an expert, especially if a person is paralyzed
or has other risk factors such as dementia, age over 75, poor
nutrition, or poor circulation.
Inspection isthe crucial component of care and prevention and can
also catch problems in the early stages, when they are much easier
to cure. Unfortunately, inspection can also be undignified at best
and humiliating at worst. I remember an enormous uproar because a
state memo went out ordering social workers to examine nursing home
residents for bedsores. There is no decent way to ask someone to
let you look at his or her backside, especially if you are not a
doctor or nurse. After a flurry of testimony and anguished letters,
the order was withdrawn.
- Well-trained nurses' aides are the most important front-line
defense. These hard working women and men do the bathing and
toileting, change bedding and clothing, and perform the most
intimate personal care services. If they are well educated and
alert to the possibility of bedsores, they are the best defense.
While the family can be helpful in repositioning, supporting the
hands-on caregivers, and keeping an eye on good care, they rarely
see the family member nude. I don't know about you, but I never saw
my father naked, and hope I never will.
Often the situation that precipitates a bedsore makes it very
challenging to treat. Conditions such as diabetes, thin skin, and
immobility make healing difficult. As noted, Stage I bedsores will
usually disappear if repositioning is prompt and consistent. A
physician's written orders can help this happen.
Stage II, when a wound is present, calls for a
multi-disciplinary approach coordinating the physician, the nurses,
the aides, and perhaps a physical therapist. Sometimes a social
worker can help manage the personal care services provided. A
careful analysis of how the wound was precipitated will help
determine treatment. A change of bed, cushioning, skin care, and/or
clothing may be effective. Support surfaces are particularly
important and special padding such as sheepskin or waffle foam can
help. Low-air-loss beds use inflatable pillows for support;
air-fluidized beds suspend the patient on an air-permeable mattress
that contains millions of silicon-coated beads.
Improved nutrition can aid healing. Dark red, orange, and green
vegetables are especially rich in the needed nutrients, and
nutritional supplements of Vitamin C and zinc can also be
Cleaning is crucial. Open sores may be treated with a saline
(saltwater) solution each time the dressing is changed. Be sure
that the issue of pain is well addressed. "Rubbing salt into the
wound" may be a cliché, but it's also the description of torturous
pain. Continence issues are important-perhaps a catheter might be
used until the wound is healed. Medication modification,
incontinence pads, and more frequent toileting also might be
helpful and less invasive.
Debridement is the removal of damaged tissue. Surgical
debridement is often recommended to remove dead, damaged, or
infected tissue. Nonsurgical treatments include irrigation with
pressurized water, hydrotherapy in a whirlpool bath, using the
body's own enzymes, or applying topical debriding enzymes.
Dressings help speed healing and protect the wound. It is
crucial to keep surrounding skin dry and the wound moist.
Transparent, semi-permeable dressings can help retain moisture and
encourage new skin to grow. Infected wounds may be treated with
topical antibiotics. Again, it is crucial to also treat the pain in
this difficult process.
Even with the best medical care, bedsores may requiresurgery.
Healthy tissue may be taken from one part of the body to use in
reconstructing the damaged area. Recovery is long and arduous with
frequent complications. Prevention is still the best
Bedsores and Nursing Homes
The highest percentage of people with bedsores are in nursing
homes. Some bedsores may have been acquired in the hospital, and
then persisted when the person transferred to a skilled care
facility. The prevalence varies from study to study, and facility
to facility, but anywhere from 3 to 28% of the people in a nursing
home may have bedsores.
It's a chicken and egg situation: which came first, the bedsore
or the environment? Often frail older people come to live in a
nursing home because this injury is so difficult to prevent and
treat at home. Sometimes the conditions that necessitate living in
a nursing home, such as advanced dementia or paralysis, create the
Federal regulations are particularly stringent about preventing,
documenting, and treating bedsores. The website www.medicare.gov (click on "Compare Nursing
Homes in Your Area") gives the ratings for every nursing home
and tells you the percentage of residents with bedsores and how
that compares with the national average.
While this is useful information, a few caveats are in order.
One nursing home may specialize in some personal care services such
as wound care, and thus have a much higher number of cases of
bedsores than another facility. Some facilities specialize in dementia
care, where most residents are mobile, and thus have a low
number of people with bedsores. So the percentage of residents with
bedsores may not necessarily be a measure of quality of
Jeannette Franks, PhD, is a passionate
gerontologist who teaches at University of Washington and Bastyr
University; she is the author of a book on assisted living and