What is Bedsore & How Does it Occur?

A bedsore is a skin lesion, which is also called as Decubitus ulcer or pressure ulcer or pressure sore. It is an open wound on the skin.

A bedsore is an injury to the skin and its underlying tissues caused due to prolonged pressure (or friction) on the skin. Hence, they are also called pressure sores or pressure ulcers.

Healthy and mobile people can constantly change their positions. However, such movements are not possible for patients who are terminally ill, paralyzed, suffering from spine injuries, and in case of very old and weak patients. The medical condition limits their ability to change positions due to which they are confined to bed or a wheel chair. The constant and long-time pressure of the bed develops ulcers on their body. They most often occur on the skin covering the bony areas such as the heels, ankles, hips, tailbone, shoulder blades, elbows, knees, even space between the fingers.

Bedsore develops in four stages as, stage I, II, III and IV. Each stage of bedsore has its own symptoms as follows:

• Symptoms of Stage I Bedsore: The characteristic features of bedsores in initial stage are –
  • The skin is unbroken
  • The skin shows discoloration
  • It is tender, warm, and painful as compared to the surrounding skin.
• Symptoms of Stage II Bedsore: These include –
  • The outer layer of the skin or the underlying layer is damaged or lost
  • The wound may be shallow and red in colour
  • It may appear like fluid-filled blister.
• Symptoms of Stage III Bedsore: The stage III bedsore symptoms are –
  • The skin loss is more
  • The ulcer looks like a crater
  • The ulcer may have dead tissue
  • The wound may extend to the deeper layers of skin.
• Symptoms of Stage IV Bedsore: Symptoms of bedsore at this stage includes –
  • The ulcer shows a large-scale loss of tissue
  • The wound may expose muscle, bone or tendons
  • The bottom of the wound contains dead tissue that’s yellowish or dark and crusty
  • The damage often extends beyond the primary wound.

There is another type of bedsore which cannot be categorized into any of the above stages. This unclassified ulcer in which the surface is yellow, brown or black and it is not possible to determine how deep is the wound.

In most cases, bedsores or pressure sores affect patients over 70 years old who are bedridden in hospitals and are in long-term care facilities. Bedsores are also associated with high mortality rate. Pressure ulcers resulted in 29,000 deaths worldwide in 2013 which is higher from 14,000 deaths in 1990. All over the world a number of patients with hospital care and home care facilities develop these bedsores. There is a much higher rate of 8% to 40% patients in intensive care units suffering from bedsores.

The healing of a bedsore depends on its stage. Stage I and II bedsores are reversible while stage III may be life threatening and stage IV bedsore is fatal. The treatment outcome is good for the stage I and II bedsores. Later stages of bedsores often require very aggressive treatments. Thus, if discovered early they are treatable.

Bedsores are caused due to the following reasons:

• Bedsores Occur Due to Continuous Pressure: Due to certain medical conditions the patients cannot move from the bed or the wheel chair. There is a constant pressure from the bed onto the skin, which cuts off the skin’s blood supply. This causes injury to the skin cells and they die, resulting in bedsores. With additional pressure, the bedsores progress in their stages of development and can be fatal if unattended.
• Friction Causing Bedsores: Friction involves causing damage to the superficial blood vessels directly under the skin. It occurs when two surfaces are rubbed against each other. This happens when a patient is transferred from a bed to a stretcher.
• Bedsore Occur Due to Shear: Shear means separation of the skin from underlying tissues. When a patient is partially sitting up in the bed, their skin may stick to the bed sheet where the underlying tissues too move downwards.
• Bedsores Occur Due to Excessive Moisture: It occurs during increased perspiration and with urinary or faecal urgency or incontinence. This condition softens the skin and reduces its resistance to bedsores.

In addition to these, there are risk factors which increase the chances of bedsores:

• Poor nutrition
• Diabetes
• Anemia
• Stroke
• Alcoholism
• Edema
• Fractures
• Cancer
• Smoking history
• Very old age
• Dry skin.

Bedsores can develop in some people with just a few hours of constant pressure and range from mild reddening to severe craters that extends into the muscle and bone.

The patient who is bedridden or confined to a wheel chair should be watched for signs and symptoms of bedsores according to the characteristics mentioned in the stage. Caregiver must observe for:

• Size and depth of the bedsore
• Type of the tissue affected
• Colour of the skin affected
• The amount of tissue death
• Condition of the ulcer in terms of presence of infection, foul odour and bleeding.

A doctor can diagnose a bedsore by just seeing it.

The treatment of bedsore depends on the stage (severity) of the ulcer. The Bedsore treatment includes medications, therapies and even surgery.

• Since bedsores are prone to infection, hence antibacterial/antiseptics are used to treat the infection.
• Debridement option is used to remove dead tissue and to clean the wound.
• Bedsores should be kept clean which will allow quick healing. The doctor may have to do frequent dressing changes of the wound, which includes synthetic dressings, saline dressings, acetic acid compresses, and various antibiotic dressings. These dressing protect the wound from bacterial biofilm formation and help to accelerate healing.
• Dressings with cadexomer iodine, silver, or honey have been shown to penetrate bacterial biofilms.
• In case of the severe wounds, surgery may be necessary to remove areas of dead skin and lower the risk of cancer in future. Typically, a pad of muscle, skin, or other tissue from the patient’s body is used to cover the wound and cushion the affected bone (flap reconstruction).
• The important step in treatment of bedsore is frequent repositioning of the person.

The time period taken for the bedsores to heal depends on its stage. Bedsore at stage I and II respond quickly to treatment as compared to stage III and IV bedsores. It also depends on how quickly the patient responds to the treatment.

It is better to prevent bedsores than treat them. The following procedures can be followed:

• The best way to prevent bedsores is by moving the patient around frequently to avoid constant pressure against the body and to redistribute the body weight and promote blood flow to the tissues. The patient can be made to change position after every 2 hours or every 15 min if seated in the chair. Pillows or foam wedges and range of motion exercises can improve circulation and maintain joint mobility.
• The bed should not be elevated more than 30 degrees to reduce shearing forces. A pull sheet can be helpful to reposition the bed.
• Some support surfaces, including anti-decubitus mattresses and cushions, contain multiple air chambers that are alternately pumped can be used to ensure ventilation.
• Controlling the heat and moisture levels of the skin surface, known as skin microclimate management, also plays a significant role in the prevention and control of bedsores.
• Taking good care of the skin is a must. The skin of the patient should be inspected and cleaned regularly. It should be kept dry and clean to prevent infection and development of potential bedsores. Affected skin should be gently washed with plain water and mild soap with very less friction. Next, a moisturizing lotion can be applied and massaged gently. Heavier agents such as Zinc oxide and aluminium paste must not be used.
• Eating nutritious food especially containing Vitamin C helps to prevent bedsores.
• Quit smoking and daily exercising helps in blood circulation.

Bedsores are caused due to injury to the skin. These are common among old or terminally ill patients with restricted movement and are confined to bed or a wheelchair. If discovered early bedsores are treatable. While advanced staged bedsores maybe difficult to treat easily. In such cases surgery may be used. Rather than treatment, it is always better to prevent them by frequently repositioning the patient, eating balanced diet and keeping skin free from exposure to moisture.