Pressure Ulcers (Bedsores): Causes, Symptoms & Treatment

Bed sores, bedsores or pressure ulcers are the destruction of the skin and underlying tissues. The deeper the sores, the more difficult they are to heal. Pressure relief is the most important prevention and treatment of pressure ulcers.

What is pressure ulcer (bedsores)?

Decubitus (decubare, Latin: to lie down) is what doctors call a chronic wound caused by mechanical overuse. Depending on the severity, doctors distinguish 4 stages of decubitus. In stage I of decubitus, the skin shows a reddened area that is often sharply demarcated. The redness does not disappear spontaneously after pressure relief. In II stage pressure ulcer, a blister has formed due to the detachment of the epidermis. In the III stage of decubitus, the epidermis and subcutis in the affected area have died (necrosis). The connective tissue under the skin as well as muscles may already have been attacked by inflammatory processes. At this point, at the latest, doctors speak of a pressure ulcer. Bare, inflamed bone sites characterize the IV stage of pressure ulcer.

Causes

Pressure ulcers are caused by persistent or regularly occurring strong pressure on the skin. In this case, the external pressure is greater than the blood pressure in the finest blood vessels (capillaries), thus cutting off the blood supply. The undersupply of oxygen and nutrients to the skin causes it to die, and inflammation of the dead tissue occurs. This infection with pathogens spreads to still healthy tissue and leads to ulcer-like deep holes. Because excessive external pressure is the cause of pressure sores, bedridden patients are affected in most cases. However, overweight people with sedentary jobs or disabled people in wheelchairs are also risk groups. Pressure sores are localized in exposed areas of the body where the bone is poorly cushioned with connective tissue or muscle. The sacrum, hips, shoulders, heels and elbows are therefore the most common areas of pressure ulcers.

Symptoms, complaints and signs

The symptoms of pressure ulcer are manifested by changes in the appearance of the skin. The course of the disease is divided into four stages, some of which are accompanied by great pain. Grade 1: The first sign of a pressure ulcer is a reddening of the skin that persists even when pressure is relieved. If you press on the reddened area with your finger and it does not turn whitish but remains reddened, the bedsore has reached the first degree. In addition, a slight swelling or hardening and warmth may be felt at the affected skin site. Grade 2: If the pressure ulcer progresses, it gradually penetrates deeper into the skin. The second-degree pressure ulcer is recognizable as a flat ulcer. Abrasions or blisters form on the affected area. The damage is still visible in the surface area of the skin, namely in the epidermis and parts of the dermis. Grade 3: The decubitus extends into the subcutis and the underlying tissue is also irreparably affected. At this stage, an open deep wound is present. If a germ infestation occurs, putrid odors also appear. Grade 4: The pressure ulcer extends to the muscles, bones and tendons. This tissue is also destroyed. Those affected suffer from enormous pain.

Diagnosis and progression

Diagnosing pressure ulcers is primarily a matter of observation. A visual inspection should focus on the parts of the body that are particularly at risk. Thus, even a layperson can recognize the pressure ulcer in the early stages by means of red skin spots. Even a pressure sore of grade II is so conspicuous that no one can overlook it. Of course, the physician will take a swab from the wound to initiate the correct treatment. The question of the pathogens involved plays a decisive role in the means chosen. In the case of a very deep pressure ulcer, an x-ray may be useful to assess the exact extent of tissue damage. Healing a pressure ulcer is usually a very lengthy process because it is an inflammatory and necrotic process. Particularly serious is the tendency of the pressure sore to eat deeper and deeper. The open, bacterially infected part of the body always means the danger of a spreading infection. Thus, blood poisoning due to pressure sores is a risk that must always be taken into account.Bone marrow inflammations can also result from the pressure sore, even the pathogens of pneumonia make their way across the gaping pressure sore. Finally, pain as well as the knowledge of an open and deep wound also lead to psychological disorders. Thus, depression and apathy are often also the result of a pressure sore.

When should you go to the doctor?

A pressure sore represents a serious wound that must be treated professionally. The basis of all things is to prevent a pressure sore by taking appropriate measures. If a pressure ulcer has nonetheless developed, a nurse must be called in as a minimum. It is not advisable for family caregivers to take action on a pressure ulcer themselves without guidance from a physician. A pressure ulcer always requires professional treatment. At the same time, even before the pressure ulcer heals, improved measures must be installed to prevent recurrence. Special anti-decubitus mattresses prevent pressure ulcers from forming in bedridden patients. Wound care is directed according to the type and severity of the pressure ulcer. Small and dry pressure ulcers can be loosely covered with sterile dressing material. Weeping pressure ulcers must first be cleaned with sterile saline. An airtight hydrocolloid dressing can then be applied. This keeps the wound moist. The weeping pressure ulcer can heal without sticking to the applied plaster dressing. In the case of an advanced pressure sore, dead tissue becomes a problem. This must be removed by a physician, observing sterility. Wound cleansing is complex. It is performed in several phases. It is necessary to take regular wound swabs to rule out infection. If necessary, treatment with antibiotics is unavoidable. Particularly deep pressure sores require hospitalization and surgical intervention.

Treatment and therapy

Treating bedsores means first and foremost relieving pressure. A bedridden patient must not only lie on his or her back, but must be repositioned every 2 hours, around the clock. This is done according to a set plan, which is designed so that the patient does not lie on one side of the body too often. The nurses use positioning aids in the form of anatomically adapted pillows to give the patient the necessary support in bed. Special decubitus mattresses adapt plastically to the shape of the body and distribute the pressure more evenly by lying on them. Waterbeds are particularly effective against pressure sores in the same way, as are water pillows that can be tucked under the sheet. Wound treatment for pressure ulcers by rinsing with potassium chloride solution or hydrogen peroxide aims to combat infection. Preparations in powder form such as silver nitrate also counteract inflammation. The doctor surgically removes dead tissue parts and thus also removes a large part of the bacteria involved. In the event of a general spread of inflammation, oral administration of antibiotics is an unrelenting therapy for pressure ulcers.

Outlook and prognosis

Healing of pressure ulcers depends on several influencing factors. The stage of the sore, as well as the underlying disease present and the age of the patient, are the most important criteria in making the diagnosis. The sooner a pressure sore is recognized and treated, the better the chances of healing. If there is a possibility that the patient’s underlying disease will heal, he is no longer dependent on bed confinement. In these cases, the sores usually heal completely within a few weeks. If the affected person is confined to bed confinement or sitting in a wheelchair, the prognosis worsens. A cure is nevertheless possible. At the same time, however, the risk of developing the pressure sore again after recovery increases. Without treatment, poor wound healing leads to further deterioration of health in most cases. If it progresses unfavorably, secondary diseases set in, leading to long-term treatment or permanent damage. If germs penetrate the wounds, there is a risk of blood poisoning. Under poor conditions, the patient may die prematurely. People of an older age naturally have a weaker wound healing process. Under certain circumstances, the pressure sore may not heal despite medical care.These patients experience a chronic course of the disease.

Prevention

Preventing pressure ulcers by relieving pressure has long been standard in modern nursing care. In addition to repositioning the bedridden patient and positioning aids, skin care measures are an important consideration. Special oils and emulsions help to keep the skin healthy, and circulation-enhancing agents such as rubbing alcohol should be used daily. If possible, caregivers should gradually mobilize the patient. Finally, these activating care measures are not just pressure ulcer prevention.

Follow-up care

After a pressure ulcer heals, adequate follow-up care of the affected area should be provided. In consultation with the attending physicians, nurturing creams, hygiene measures, and care of the wound or scar area should be applied here. In addition, care should be taken to protect the skin and surrounding soft tissues, both for aftercare and to protect against further decubiti. This applies above all to areas that are subject to particular mechanical stress. For example, shoes that are too tight should not be worn and lying in one position for too long should be avoided if possible. Here, for example, cushioning pillows can be placed under the heels. In the case of chronically bedridden patients, it is advisable to change the lying position several times a day and also to support this with soft blankets or pillows. It is also advisable to have a decubitus mattress prescribed by a doctor, which inflates electrically to reduce the pressure on the bed. For prevention, existing diseases such as diabetes or circulatory disorders should be controlled with medication. This is also important if patients tend to suffer from decubitus sites that have not yet healed completely, since underlying diseases promote wound healing disorders and bacterial infections. If individually possible, weight reduction should be aimed at, especially in overweight patients. Likewise, attention should be paid to an adequate drinking quantity.

What you can do yourself

The measures that those affected by a pressure sore can take themselves to treat or even prevent a corresponding wound depend on the degree of their existing mobility and their ability to perceive the affected parts of the body correctly. The first priority for those affected is communication with relatives or caregivers. Even if a pressure sore is suspected or irritation is felt in an inaccessible part of the body, urgent attention should be paid to checking it. Hygiene measures are also relevant and should be enforced. Especially after defecation or urination, affected body parts must be washed. Otherwise, the risk of pressure sores increases or an already existing wound is further irritated. The diet should be rich in vitamins and minerals to strengthen the skin. Sufficient fluids are also recommended. Massages of little moved or otherwise endangered body parts also help. Here, substances that stimulate blood circulation are particularly suitable as massage oils. Rosemary or peppermint come into consideration here. In the case of already affected areas, it is important that no pressure points are created during storage. Tubes, folds from clothing or bedding and the like must be removed or avoided. Clothing that is too tight should also be avoided. For wound care, calendula ointments are supportive. However, the possibilities for self-help depend very much on the other symptoms of the disease. Affected persons who have very limited mobility should not be shy about communicating regarding hygiene and other measures.