Last Updated: April 9,
By Jeannette Franks, PhD
Family members with someone in long-term
care need to be knowledgeable and vigilant about decubitus
ulcers -- the dreaded bedsores.
Also called pressure sores, pressure ulcers or decubitus ulcers,
bedsores are skin wounds that result from prolonged pressure on the
skin that's 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. The tailbone
(coccyx), shoulder blades, hips, heels and elbows are common sites
for bedsores. 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 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.
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 are shear and friction:
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.
Bedsore Risk Factors & Stages
Age is the greatest risk factor for bedsores; the older the
person, the more vulnerable their skin. In an immobilized older
person, even a small skin tear, which could easily occur during
routine activities such as transferring from bed to a wheelchair,
might quickly develop into a bedsore. Other risk factors include
smoking, lack of pain perception, urinary or fecal incontinence,
malnutrition, dementia and other medical conditions such as
Bedsores develop in stages:
- 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 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 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.
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.
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
Inspection is crucial to detecting bedsores in the early stages of
formation, when they are much easier to cure. While this requires
caregivers to get up close and personal with patients, it's a
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.
There are several things that can aid with healing:
- Improved Nutrition
Dark red, orange and green vegetables are especially rich in the
needed nutrients, and nutritional supplements of Vitamin C and zinc
can also be helpful.
- Regular Wound Cleaning & Debridement
Open sores may be treated with a saline (saltwater) solution each
time the dressing is changed. 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
The right bandaging can 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 require surgery.
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 & 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 numerous articles.