A bedsore is a wound which erupts from a localized breakdown of the skin and subcutaneous tissues, usually over a boney prominence. The primary cause of bedsore formation is the application of sustained pressure over time. For this reason, they are also known as “pressure injuries” or “pressure ulcers.” The sustained application of pressure interrupts the flow of blood to the skin and surrounding tissues. If this pressure remains in place long enough, the affected tissues dies and a wound forms. Bedsores can strike anyone, regardless of age, although a person’s overall state of health can increase the risk of formation. Persons at risk include anyone who is unable to reposition themselves, including folks who are bedridden or wheelchair bound, restrained, sedated, comatose or paralyzed.
It’s not the amount of pressure applied but rather the time the pressure goes unrelieved which matters. As such, pressure injuries a/k/a “bedsores” can develop in any facility, including hospitals, and generally form on areas like the buttocks, back, elbows and heels. Tragically, bedsores are a common injury amongst elderly residents in nursing homes or assisted living facilities. These wounds are very serious and can be life threatening. When properly managed, most pressure injuries can be brought under control and healed. However, if not treated correctly, they can be life-threatening.
The typical causes of bedsores (a/k/a “pressure injuries” or “pressure ulcers”) include:
Pressure:As the name implies, sustained pressure causes the skin over boney prominences to break down due to a loss of blood flow. The generally accepted standard of care for prevention of pressure wounds is to turn and reposition the patient by at least 30 degrees once every two (2) hours. Short of that, the pressure caused by the patient’s weight pressing against their bed, chair, etc., can cause the skin to break down. Once the skin begins to die, an open sore, known as an “ulcer” will typically form, which can grow progressively worse, until it ultimately includes the subcutaneous fat, muscle and connective tissue. The depth and degree of the wound will depend on the duration and extent of pressure which the person has been subjected to.
Friction:Sustained friction on the same point of skin can also cause pressure wounds to form or worsen. In basically the same manner as sandpaper wears down wood, sustained friction can remove skin one layer at a time. For residents of nursing homes, one common cause of friction injury can occur if the facility’s staff is aggressive in their efforts to position the patient, and repeatedly pull them on and across the bedding.
Shearing Force:Shearing force refers to the application of a force which stretches the skin. For elderly patients in a nursing home, shearing forces can be applied to their skin if the facility’s staff improperly positions them in a bed or chair. For example, if a person is incompletely propped up, the force of gravity can cause them to slide down under the weight of their body, while the top surfaces of their skin are held in place by the pressure against the bed or chair, creating a shearing injury. Shearing can act in isolation or in combination with other factors to give rise to a wound.
Other factors:A variety of other factors can act in concert to increase the risk that pressure injuries will form. Amongst the most important of these are: 1) Excessive Moisture; 2) Sustained exposure to feces; 3) Dehydration; and 4) Malnutrition. Incontinence is a common issue amongst nursing home residents. If they are not regularly changed, or are permitted to sit in feces, the exposure to excessive moisture and feces can damage the skin, increasing the likelihood of break down and ulcer formation. Similarly, a person’s nutritional status and hydration levels can impact their ability to heal and increase the likelihood that wounds will form.
The severity of a pressure wound is described by its “stage”. The more serious the damage, and deeper the wound, the greater its stage. Bedsores, a/k/a pressure injuries, are staged from I – IV, with stage I being the least severe and stage IV being the most severe. The typical features of the various stages are as follows:
Stage I:A stage I wound is relatively mild and is characterized by an area of intact skin with non-blanchable redness of a localized area usually over a bony prominence. This means that when one presses on the area, it remains red rather than turning white (“blanching”) under the pressure of the touch. The affected area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. As noted above, the skin is intact. No ulcer is present. A stage I wound can usually be healed with relative ease if the patient is given appropriate care.
Stage II:A stage II wound typically appears as blistering of the skin or a small ulcer. Sometimes, it may resemble a scrape or abrasion and may be called a “skin tear.” The amount of skin loss it typically shallow and may have a reddish or pink base. The blisters associated with a stage II bedsore may fill up with clear fluid, pus, or even blood.
Stage III: A stage III wound will have progressed to an ulceration through the skin and into the fatty tissues and subcutaneous layers, but without exposing the bone. The edges may appear black and there may be necrotic (dead) tissue present. Stage III wounds are fairly gruesome.
Stage IV:A stage IV wound will present as an open ulcer or hole, which progresses through the skin and underlying muscle tissue, and which exposes the underlying bones, tendons and surrounding muscle tissues. Stage IV wounds are extremely gruesome in appearance. Once you’ve seen one, you’re unlikely to ever forget it. It is generally accepted that a stage IV wound should never occur if the patient is given proper care.