Bedsore Stages
AKA:  Decubitus Ulcers, Pressure Ulcers, Pressure Sores, Bed Sores, Dermal Ulcers, Pressure Wounds

Photograph courtesy of Ila Swan

Anyone who must stay in a bed, chair or wheelchair because of illness or injury, or who cannot change position without help is at high risk. Seniors are particularly vulnerable because their skin usually becomes thinner and more fragile with age. Bedsores can develop in a matter of hours. Decubitus ulcers can happen during hospitalization, in a nursing home or in a community setting.

A pressure ulcer is an injury caused by constant pressure to the skin and muscle and/or by shearing forces. The severity ranges from mild, affecting the skin surface only, to severe when a deep decubitus ulcer reaches down to muscle and bone.

When a person cannot change position, pressure closes tiny blood vessels that nourish the skin and supply oxygen. When the skin lacks nutrients and oxygen for too long, the tissue dies and a bedsore forms.

Pressure ulcers are extremely difficult to heal. The resulting wound can be painful, destroy tissue, fat, muscle and even lead to death. 
Most pressure ulcers can be prevented.

Pressure Ulcer Stages

Pressure ulcers are localized areas of tissue damage, often over a bony prominence. Their diameter may not as important as their depth. These ulcers are classified in stages according to the severity of the wound.

Photograph courtesy of Ila Swan
Several stages of wounds can be present at the same time.

Stage 1

The skin is intact but shows a persistent pink or red area that does not turn white when you press it with your finger. The wound may look like a mild sunburn. The affected skin may be tender, painful or itchy. It may feel warm, spongy or firm to the touch.

The wound is superficial and heals spontaneously when pressure is relieved.
A Stage 1 pressure ulcer is an early warning of a problem and a signal to take preventive action.

Stage 2

The skin starts to breakdown and there is partial thickness skin loss. The wound looks like an abrasion, a blister (broken or unbroken) or a shallow crater.

Photograph courtesy of Ila Swan

The skin outer layer is broken, red and painful.

Photograph courtesy of Ila Swan

Surrounding tissues may show areas of pale, red or purple discoloration. Some swelling and/or oozing may be present.

The wound is no longer superficial and the ulcer is an open sore that does not extend through the full thickness of the skin.
A Stage 2 pressure ulcer can usually be treated successfully. With quick attention, the wound can heal rapidly.

Development beyond stage 2 tends to indicate a lack of aggressive and timely intervention.

Stage 3

The skin has broken down and the wound now extends through all layers of the skin. The ulcer has become a crater involving damage or necrosis of subcutaneous tissues.

Photograph courtesy of Ila Swan

The pressure ulcer has become deeper and very difficult to heal. At this stage, a large percentage of patients may require treatment of up to one year. The wound is now a primary site for a serious infection to occur.

A Stage 3 wound will progress very rapidly if left unattended. Medical care is necessary to promote healing and to treat and prevent infection.

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  Stage 4

There is full-thickness skin loss with extension beyond the deep fascia and involvement of muscle, underlying organs, bone, and tendon or joint space.

Photograph courtesy of Ila Swan

This deep open wound may show blackened tissue called eschar.

Photograph courtesy of Ila Swan

The decubitus ulcer is now extremely deep, having gone through the muscle layers and now involving underlying organs and bone. Surgical removal of the necrotic or decayed tissue is often used on wounds of larger diameter. Surgery is the normal course of treatment.

The wound is very serious and can produce a life threatening infection, especially if not treated aggressively. A Stage 4 wound is extremely difficult to heal and requires skilled medical wound care.

Prevention

Pressure ulcers are easier to prevent than to cure. A general guide to prevention from the National Pressure Ulcer Advisory Panel (NAPUAP) is available online in pdf format.

Risk Assessment
Prevention strategy starts with recognizing the risk to the patient. Early identification of individuals at risk can lead to a timely intervention to prevent or reduce the danger.

Risk factors assessed can include: general physical condition, nutrition, activity, mobility, friction, sensory perception, incontinence, skin moisture, level of consciousness, mental status. After a decubitus ulcer has healed, the skin does not fully recover and future risk is significantly increased.

Several risk assessment charts are available:

• Pressure Ulcer Risk Assessment
  from healthandage.com

• Scales for Predicting Risk of Pressure Ulcer
  from the Medical Algorithm Project
  Includes a selection of scales including: the Norton Scale, the Braden Scale and the Gosnell Scale.

• Care Risk Factor Chart
  from the National Pressure Ulcer Advisory Panel (NAPUAP) in pdf format

• Pressure Ulcer Risk Assessment Scale: The Missing Link
  by Kenneth Olshansky, MD on the Decubitus.org Website

If the test result indicates a significant risk, discuss prevention with caregivers and nursing home staff.

Monitor the patient’s progress and the results of inspections at home, in a hospital setting or in a nursing home. Horror stories abound where family members are surprised by a “sudden” hospitalization with a stage 3 or 4 decubitus ulcer. This sometimes occurs shortly after admission into a nursing home.

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Daily Inspection

Make a thorough daily skin inspection giving particular scrutiny to bony prominences. Because the initial stages of skin breakdown cannot always be seen clearly, the visual inspection should be accompanied by palpation for areas of increased temperature or excessive firmness. Regular documentation of the skin examination should be made.

Documentation
Beyond regular documentation of the preventive skin examination, records made during the course of treatment should include specifics about the size, location, stage of wound, presence of odor, presence of purulent drainage and condition of surrounding tissues.

Cleaning & Moisture
Wetness can increase the skin's vulnerability to damage from pressure. Moisture softens the skin and increases the risk of breakdown. Sources of moisture include sweat, wound drainage, urine and feces. For this reason, patients who suffer from incontinence are at particularly high risk for bedsores.

Photo Courtesy of Ila Swan

If incontinence cannot be controlled, use absorbent pads as necessary to draw moisture away from vulnerable areas and cleanse the skin at time of soiling.

Assess and treat incontinence. If the patient is incontinent, ask your doctor about ways to control or limit the leakage of urine or feces.

Avoid using irritating antiseptics, hydrogen peroxide or other harsh chemicals to clean or disinfect the skin. The skin should be cleaned with warm water or saline (a non-irritating salt solution) rather than harsh soaps, using minimum friction. Moisturizers help to alleviate dry skin.

Infection
Because the broken skin of a wound is a prime target for bacteria, pressure ulcers are extremely vulnerable to infections. This is especially true if the urine or feces of an incontinent patient frequently contaminate the sore.

Signs of infection in a bedsore include:

• Pus draining from the sore,

• A foul-smelling odor,

• Tenderness, heat and increased redness in the surrounding skin,

• Fever.

Photograph courtesy of Ila Swan
Infected decubitus ulcer with maggot

The National Pressure Ulcer Advisory Panel reviews frequently asked questions on wound infection and infection control in this Web page.

Be alert for the possibility that a wound might get infected. This infection can become life threatening.

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Pressure relieving strategies

A pressure ulcer is an injury caused by constant pressure to the skin and muscle. When a person cannot change position, pressure closes tiny blood vessels that nourish the skin and supply oxygen. Unless pressure is relieved and normal circulation resumes, the affected skin soon begins to show signs of injury. The resulting wound can destroy tissue, fat, muscle and even lead to death.

Pressure as small as 60 mm Hg. to a body surface for 1-2 hours initiates the process of skin breakdown. Shear, friction, moisture and chemical irritants exacerbate the process.

Bony prominences such as the spine, coccyx/tailbone, hips, heels and elbows are particularly vulnerable because the tissue is trapped between the bone structure and a hard surface.

Pressure Ulcers on Hip

Pressure Ulcers on Tailbone

Photographs courtesy of Ila Swan

Pressure sores can occur, for example, when you sit or lie in one position too long. Anyone who must stay in a bed, chair, or wheelchair because of illness or injury, or who cannot change position to relieve this pressure without help is at high risk. For this reason, use of restraints on a patient or nursing home resident increases the risk of pressure ulcers.

Simply changing position every few hours while lying in bed, or every 15 minutes while seated, significantly reduces the risk. Providing an overhead trapeze can help patients be more mobile.

A 2-hour time frame is a generally accepted maximum interval that the tissue can tolerate pressure without damage. A patient who cannot change position without assistance should be turned and repositioned at least every two hours, more frequently if needed, with the use of pillows as support.

Pressure-relieving and pressure-reducing devices have been developed for preventing pressure injury. None of these insures complete protection. Specialized mattresses can facilitate pressure reduction and appear to be effective in reducing the development of pressure ulcers when compared with standard mattresses.

Use of medical sheepskins and egg crates is controversial. Although offering more protection than standard mattresses, they relieve surface pressure only and might give a false sense of security.

Air-fluidized beds have been shown to more effectively reduce the development of pressure ulcers in patients. Low-air-loss and air-fluidized beds have been shown to consistently relieve pressure on bony prominences.

Additional protection may still be needed to relieve heel pressure. If the patient cannot move, heels must be raised off the bed. Pillows should be placed under the legs from mid-calf to ankle, not behind the knee.

Studies indicate that turning more frequently than 2 hours is needed if a standard mattress is used. If the patient is in a chair, the position should be changed every hour.

Do not use donut-shape cushions. They can increase the risk of getting a pressure ulcer by cutting off blood flow and causing tissue to swell.

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Reducing Shear Forces and Friction

Shearing is also a kind of pressure injury. It happens when the skin moves one way and the bone underneath it moves another way. Shearing and friction also cause rubbing and superficial irritation of the skin surface. This increases the skin's vulnerability to damage from pressure. Shear strains are higher where tissue between skin and bone is thin. Shear strain stretches and tears microstructures such as cell walls and capillaries.

Some important sources of shearing and friction are:

• Dragging or sliding a patient across the bed sheets,

• Allowing the patient's unprotected elbows or heels to rub against the bed surface,

• Rubbing against something such as a bed sheet, cast, brace,

• Raising the head of the bed more than 30 degrees, which increases shearing forces over the lower back and tailbone. Friction between the skin and a stationary surface holds the soft tissue in place while gravity pulls the axial skeleton down. Frictional forces and their effects are present whenever there is either sliding or a tendency to slide.

To reduce shear forces and friction:

• Avoid dragging the patient across the bed sheets. Instead, either lift the patient or encourage the patient to use a trapeze to briefly raise his or her body.

• Keep the bed free from crumbs and other small particles that can rub and irritate the skin.

• Discourage the bed or chair bound patient from sitting with head elevated more than 30 degrees except for short periods of time (unless instructed by a physician).

• Bony prominences should not be massaged.
  Use protection and padding as needed to prevent tissue abrasion.

• Sheepskin boots and elbow pads can be used to reduce friction on heels and elbows.

• Cleanse gently when washing the patient. Avoid rubbing or scrubbing the skin.

Nutrition and Hydration
Without proper nutrition and hydration, the patient is at greater risk of developing pressure ulcers and wound healing will be more difficult. Encourage the patient to eat well and monitor his or her nutritional status. Protein intake is particularly important.

Consult with an expert as needed to insure maximum nutritional support. Research indicates that good nutrition is a crucial factor in a patient’s recovery.

Encourage Daily Exercise
Look for ways to improve the patient’s ability to move. Exercise increases blood flow and speeds healing. In many cases, even bedridden patients can perform stretches and isometric exercises. Encourage the patient to use a trapeze to briefly raise his or her body. The use of restraints on a patient in a nursing home facility increases the risk of developing bedsores.

Avoid excessive bed rest and review medications, especially drugs increasing somnolence.

Education of Family and Caregivers
Education of the patient’s family and caregivers is a key function of prevention and care.

Treatment
The basic treatment of decubitus ulcers is prevention. Pressure ulcers are extremely difficult to heal once they develop. Several websites offer guides explaining treatment at different stages of the wounds:

• Taking Care of Pressure Sores
  by the University of Washington School of Medicine, Department of Rehabilitation Medicine

• Prevention and Treatment of Pressure Ulcers: What Works? What Doesn't?
  by David R. Thomas, MD in pdf format

• Pressure Ulcers in Older Adults: Prevention and Treatment
  by Howard M. Fillit, MD and Gloria Picariello, MSN, RN, CS for HealthandAge.com

• Pressure Ulcers: Prevention and Management
  from the Mayo Clinic Department of Internal Medicine

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Quality of care and liability

Almost all pressure ulcers can be prevented and their development is usually evidence of some form of neglect. Decubitus ulcers are painful, increase the risk of infection, prolong hospitalization and increase mortality. Prevention is the most humane and cost effective approach to care. When a patient is at risk, prevention is a key function of care.

Bedsores are one of the required indicators of quality of care measured and reported by nursing homes to participate in the Medicare and Medicaid programs. Detailed information including the percentage of residents with pressure ulcers for each nursing home is available on the Medicare Nursing Home Compare Website. Other indicators of quality care including the number of deficiencies, staffing ratios and percentage of residents with physical restraints are also provided on this website.

According to Medicare, the average percentage of nursing home residents with bedsores in the U.S. is 9% (August 2002 data) and 10% in California. The performance of individual nursing homes can vary greatly.
For example:  In June 2002, the percentage of residents with bedsores in Greater Hollywood Area nursing homes ranged from 0% to 49%.

Due to staffing shortages, medical funding cuts and other issues, many long-term care facilities are chronically understaffed. This results in patients not being turned, cleaned and fed as often as the ideal standard of nursing would dictate. Massive deep wounds over Stage 2 and chronic infections continue to be an unacceptable standard of care. Such wounds are generally a strong indication of negligence in more than one area.

Photograph courtesy of Ila Swan

Pressure ulcers are easier to prevent than to cure. If a nursing home allows a bedsore to develop, you should question whether the facility will be able to cure it or prevent it from getting worse.

Failure to prevent this adverse outcome carries increasing liability. The median settlement for pressure ulcer-related disputes was $250,000 in the mid-eighties. Monetary compensation for nursing home pressure ulcer cases is growing and now averages $1,000,000.

Decubitus ulcers should be viewed as a preventable injury, not an excusable one.