Bed Sores (Pressure Ulcers, Decubitus ulcers): Staging, Grading, Prevention and Treatment

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Photo of Bed Sores (Pressure Ulcers, Decubitus ulcers): Staging, Grading, Prevention and Treatment

What are Bed Sores?

Bed sores are tissue death (or necrosis) with ulceration of the skin due to prolonged pressure. Bed sores are also known as Pressure sores or Pressure ulcers. They are also called Decubitus ulcers. Whatever you called them, bed sores are skin ulcers affecting both the skin and the underlying tissues depending on the Pressure ulcer staging or Pressure sore grading. The deeper the bed sore, the higher the grade or stage of the ulcer. Some pressure sores affect the bones and these types are severe and life threatening.

Pathophysiology of Bed sores (What causes Pressure sores and how do get them?)

The main cause of bed sores is prolonged pressure on the skin over any bony prominence. This causes inadequate or lack of blood flow to the affected skin area (Tissue ischemia), leading to dead of affected skin area; sloughing off occurs and bed sores are formed; skin tissue death increases susceptible to infection. Another factor that causes pressure ulcer is friction of the skin with surfaces (especially rough surfaces) and prolonged contact with urine or feces. Pressure sore can also be caused by pressure of Plaster of Paris (POP) cast over a bony prominence, in this case, one can know that a pressure sore would occur when there is pain at any bony prominence following POP cast. To prevent POP cast pressure sores, there should be adequate padding and the plaster should not be tightly applied.

How long does it take to get bed sores?

The time taken for bed sores to occur may vary depending on the associated medical conditions that the patient has. Some patients with sickle cell anemia or diabetes mellitus tend to get bed sores within a short time than others; but the critical period to get bed sores generally is above 3 to 4 hours of applied pressure that stops the blood supply of the skin (that is, the external pressure exceeds the capillary occlusive pressure above 30mmHg. This is why it is advisable to turn patients at risk every 2 hours or 1 hour at best. You should not wait till 3 hours because the time may not be exact.

Common sites (locations of Pressure ulcers) in descending order
Common sites (locations of Pressure ulcers) in descending order


Common locations/sites of Pressure Ulcers (Bed sores, Decubitus ulcers)

  1. The sacrum, causing sacral ulcer
  2. Tibial crest
  3. Ischial tuberosities
  4. Greater trochanters
  5. Iliac spine
  6. Spinous processes
  7. The heels of the foot
  8. Medial and Lateral Malleoli (The bony prominences around the ankle)
  9. Knees
  10. Elbows
  11. Between the gluteal muscles (that is around the buttocks or above the anus): this is mostly seen in hospitalized patients lying on their backs for a long time.
People at risk of developing pressure ulcers
People at risk of developing pressure ulcers


People at risk of Bed sores (Pressure sores)

  1. Elderly individuals are commonly at risk of decubitus ulcer because the hardly move around and usually sit for long. This causes pressure over bony prominences and bed sores occur.
  2. Children: especially those who cannot walk or crawl are at risk. Extremes of ages generally pose a risk to having bed sores. Babies often wet themselves and it causes irritation of the skin and increases the risk of skin excoriation unless their diapers are changed.
  3. Disabled people: people with disabilities such as inability to move or walk are at risk of having bed sores. These debilitated people stay in one position for long hours until someone cares to help them out. They often urinate on themselves (wet themselves) or pass stool on themselves; this causes skin irritation and increases the chances of having bed sores.
  4. Unconscious patients: patients that are mostly managed in the Intensive Care Units (ICUs) often develop bed sores because they are bedridden for long and sometimes the rate of turning them may not be efficient especially in a hospital that is short staffed.
  5. Severe burns patients
  6. People at associated medical conditions like peripheral vascular disease such as Diabetes Mellitus tend to have higher risk than others.
Stages of Pressure Ulcer: from stage one to stage five according to the  American National Pressure Ulcer Advisory Panel
Stages of Pressure Ulcer: from stage one to stage five according to the American National Pressure Ulcer Advisory Panel


Pressure ulcer staging (Stages of Pressure ulcers)

  1. stage 1 Pressure ulcer shows Blanching and non-blanching hyperemia (redness of skin)
  2. Stage 2 Pressure ulcer involves Blistering of the skin
  3. Stage 3 Pressure ulcer: shows an ulcer (i) with necrosis or (ii) without necrosis
  4. Stage 4 Pressure ulcer involves deep ulceration: (i) with necrosis or (ii) without necrosis
  5. Stage 5 Pressure ulcer is a chronic ulcer (it is prolonged).
  6. Unstageable pressure ulcer, the ulcer is covered with dead tissue that you cannot see how deep it is.

Pressure sore grading (Grading of Pressure ulcer)

  1. Grade 0 Pressure sore has intact Skin with subcutaneous hematoma (area of darkening), area of thickening of skin, area of excoriation or edema (swelling)
  2. Grade 1 Pressure sore: there is superficial skin layer loss (only the epidermis is affected)
  3. Grade 2 Pressure sore: full thickness/deep skin loss (Whole dermis is involved) but the edge is not everted
  4. Grade 3 Pressure sore involves full thickness skin loss with cavity formation as far as muscles with wound edge everted
  5. Grade 4 Pressure sore: it is a grade 3 pressure sore with involvement of bones and joint cavity (underlying tissues)

The Grades of pressure sores are based on the level of skin affected and the underlying tissues

How to prevent pressure ulcers
How to prevent pressure ulcers


Pressure Ulcer Prevention (How to prevent Bed Sores)

  1. Frequently changing the position of the patients that are unconscious, debilitated, too old or too young is important in pressure ulcer prevention. This is usually done every 1 hour if possible (it is the best) or every 2 hours (standard).
  2. Encourage ambulation if possible; when the person can walk or move about, such a person should be encourage to walk around occasionally
  3. Good nutrition (A balanced diet with much of protein content) to help in maintenance of skin integrity. It also helps in healing the pressure ulcer if it has already occurred.
  4. Correction of Anemia with hematinic or blood transfusion helps maintain tissues viability and immunity
  5. Frequent checking of skins over bony prominences as listed above, for detection of early stages of pressure ulcer. The early stages of bedsores (that is, the start of a pressure sore looks like a reddish local area of the skin) are identified by redness over the part that may form the bedsore, especially when the redness does not blanch or change color on application of pressure with a finger; this points to increased pressure over the red area.
  6. Use of bed sheets that are plain and having no rough designs on it
  7. Bed sheets should not be made to squeeze
  8. Use of bedsheets should be dry and not wet. Wet bed spreads cause irritation of the skin and increases the risk of bed sores.
  9. Proper Cleaning and drying of skin especially the anal area to prevent irritation caused by feces or urine.
  10. Adequate ventilation especially in areas that are warm or moist to avoid sweating with irritation of skin
  11. Use of topical skin powder, creams or semipermeable membranes to prevent skin irritation from wetting caused by urine or feces.
  12. Use of pressure mattresses, water-filled mattresses or egg-crate pads that is thick with papillated foam also helps in the prevention of bed sores and treatment of decubitus ulcers that have formed already
  13. Use of Pressure breakers like crushing ring, sorbo ring/ring foam
  14. Prompt management or treatment of early stages of pressure ulcer to avoid further complications. See bed sore treatment below.

There is no single method or combination of methods that is effective in preventing pressure sores from occurring or healing. However, their rate of occurrence can greatly be reduced by prevention.

Pressure ulcer treatment (management of bedsore, decubitus ulcer)

Once pressure ulcer forms, it is treated just like any other type of cutaneous ulcer (skin ulcer). Prompt treatment of pressure ulcers is essential in preventing it from increasing in size and giving rise to complications that may be life threatening.

  1. Incision and drainage of necrotic tissues (infected space)
  2. Use of Platelet derived growth factor-B promotes healing
  3. Use of surgery such as split thickness skin grafts for treatment of pressure ulcers poor granulation tissue, lack of epithelia growth and necrotic edges.
  4. Use of full thickness skin grafts or rotational flaps and pedicles when the decubitus ulcer has affected the bone and periosteum.

Bed sores complications (Complications of Pressure ulcer)

  1. Wide spread systemic infection: sepsis may occur that may be lead to death when not treated
  2. Osteomyelitis may occur with bone involvement
  3. Deformity of joints or body structures especially in large decubitus ulcers
  4. Disability may occur especially around the Knee or ankles such as inability to walk.