Pressure Ulcers

What are pressure injuries?

Pressure injuries can happen when you are bedridden or otherwise unable to move, unconscious, or unable to sense pain. Pressure injuries are sores (ulcers) that happen on areas of the skin that are under pressure. The bony areas of the body are commonly affected. The pressure can come from lying in bed, sitting in a chair or wheelchair, or wearing a cast for a long time. Pressure injuries are also called pressure ulcers, bedsores, pressure sores, or decubitus ulcers. 

Pressure injuries can be a serious problem in frail, older adults. They can be related to the ability to take care of yourself or the quality of care received. Pressure injuries can develop if you must stay in bed or aren't able to move and aren't turned, and positioned correctly, or often enough. They can also develop if you're not given good nutrition and skin care. You are at higher risk for pressure injuries if you have diabetes, circulation problems, or poor nutrition.

What causes pressure injuries?

A pressure injury develops when pressure cuts off the blood supply to the skin for a long period of time. Lack of blood flow to the skin leads to skin cells dying. This first starts as a red, painful area. It then turns purple. Left untreated, the skin can break open and the area can become infected.

A pressure injury can become deep. It can extend into the muscle and bone. Once a pressure injury develops, it's often very slow to heal. Depending on the severity of the pressure injury, your physical condition, nutritional status, and the presence of other diseases such as diabetes, pressure injuries can take days, months, or even years to heal. They may need surgery to help the healing process.

Pressure injuries often happen on the:

• Buttocks area, on the tailbone or hips
• Heels of the feet
• Shoulder blades
• Back of the head
• Backs and sides of the knees or sides of the ankles

Who is at risk for pressure injuries?

Being bedridden, unconscious, unable to sense pain, or unable to move raises the risk that a pressure injury will develop. The risk goes up if you can't turn or aren't turned, and positioned correctly or often enough. Poor nutrition and skin care also increase risk. You are at higher risk if you have diabetes or circulation problems, are underweight or overweight, don't have control of your bowels or bladder, or are malnourished.

What are the symptoms of pressure injuries?

Pressure injuries are divided into 4 stages, from least severe to most severe. These are:

• Stage 1. The area looks red and feels warm to the touch. With darker skin, the area may have a blue or purple tint. You may feel that it burns, hurts, or itches.
• Stage 2. The area looks more damaged and may have an open sore, scrape, or blister. You have a lot of pain, and the skin around the wound may be discolored.
• Stage 3. The area has a crater-like appearance because of damage below the skin's surface.
• Stage 4. The area is severely damaged, and a large wound is present. Muscles, tendons, bones, and joints can be affected. Infection is a large risk at this stage.

A pressure injury is identified as un-stageable when there is full-thickness tissue loss and the base of the sore is covered by dead tissue (slough) or a scab (eschar) is found in the wound bed. The dead tissue may be tan, grey, green, brown, or yellow. Eschar is usually tan, brown, or black. Deep tissue pressure injury is seen with skin that may or may not be damaged but has a red or purple color. If the injury is open, the surface is dark or may look like a blister filled with blood.

How are pressure injuries diagnosed?

Healthcare providers diagnose pressure injuries by looking at your skin if you are at risk for these sores. The pressure injuries are staged according to how they look.

How are pressure injuries treated?

Specific treatment of a pressure injury is discussed with you by your healthcare provider and wound care team. It's based on how serious the injury is. Treatment may be more difficult once the skin is broken. It may include:

• Removing pressure on the affected area
• Protecting the wound with medicated gauze or other special dressings
• Keeping the wound clean
• Ensuring good nutrition
• Removing the damaged, infected, or dead tissue (debridement)
• Transplanting healthy skin to the wound area (skin grafts)
• Negative pressure wound therapy
• Medicines such as antibiotics to treat infections

Healthcare providers will watch the pressure injury closely. They will take note of the size, depth, and response to treatment.

What are possible complications of pressure injuries?

Once a pressure injury develops, it can take days, months, or even years to heal. It can also become infected, causing fever and chills. An infected pressure injury can take a long time to clear up, or even turn into a chronic wound that doesn't heal. In severe cases, the infection can affect the underlying bone (osteomyelitis). As the infection spreads through your body, it can also cause mental confusion, a fast heartbeat, and generalized weakness.

What can I do to prevent pressure injuries?

Pressure injuries can be prevented by inspecting the skin for areas of redness every day. The redness is the first sign of skin breakdown. Pay special attention to bony areas.  Other ways to prevent pressure injuries and prevent existing pressure injuries from getting worse include:

• Turning and repositioning at least every 2 hours
• Sitting upright and straight in a wheelchair, changing position every 15 minutes
• Providing soft padding in wheelchairs and beds to reduce pressure
• Providing good skin care by keeping the skin clean and dry
• Providing good nutrition. Without enough calories, vitamins, minerals, fluids, and protein, pressure injuries can’t heal, no matter how well you care for the sore.

Key points about pressure injuries

• Pressure injuries are ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a chair or wheelchair, or wearing a cast for a long period.
• Pressure injuries can happen when you are bedridden, unconscious, unable to sense pain, or immobile. Poor nutrition and skin care increase the risk of developing pressure injuries.
• Pressure injuries can be prevented by checking the skin for areas of redness every day, with special attention to bony areas, and following the recommended strategies to prevent pressure injuries.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your healthcare provider tells you.
• At the visit, write down the name of a new diagnosis and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your healthcare provider if you have questions.