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Bed Sores (Pressure Ulcers): Causes, Prevention, Stages & Treatment

Bed Sores (Pressure Injuries): Complete Prevention & Care Guide

Bed sores (pressure injuries, pressure ulcers, decubitus ulcers) are localized damage to skin and underlying tissue caused by sustained pressure, often combined with shear and friction. They're a major quality-of-care indicator in healthcare settings.

Pathophysiology

Pressure > capillary closing pressure (32 mmHg) → ischemia → reperfusion injury → tissue necrosis. Shear forces stretch and tear capillaries; friction damages superficial layers.

Common Sites (Bony Prominences)

  • Sacrum/coccyx (supine)
  • Heels (supine)
  • Ischial tuberosities (sitting)
  • Greater trochanters (side-lying)
  • Malleoli, elbows, scapulae, occiput

Risk Factors (Braden Scale Domains)

  • Immobility/limited mobility - Primary driver
  • Sensory impairment - Spinal cord injury, neuropathy (can't feel discomfort)
  • Moisture - Incontinence, diaphoresis, wound drainage → maceration
  • Nutrition - Protein-calorie malnutrition, dehydration, vitamin C/zinc deficiency
  • Vascular compromise - Diabetes, PVD, heart failure, smoking
  • Age - Thinner skin, reduced collagen, slower healing
  • Weight loss - Less padding over bony areas
  • Medications - Steroids, vasopressors, chemotherapy

Staging System (NPUAP/EPUAP)

StageDescription
Stage 1Non-blanchable erythema of intact skin
Stage 2Partial-thickness skin loss with exposed dermis
Stage 3Full-thickness skin loss; adipose visible; no muscle/bone exposed
Stage 4Full-thickness skin/tissue loss; muscle, bone, tendon exposed
UnstageableObscured full-thickness loss (slough/eschar)
Deep Tissue Pressure InjuryPersistent non-blanchable deep red/maroon/purple intact skin

Clinical Signs

  • Skin color changes (red, purple, blue - non-blanchable)
  • Temperature change (warmer/cooler than surrounding)
  • Texture change (induration, bogginess)
  • Pain or tenderness (if sensation intact)
  • Blistering, open wound, eschar
  • Foul odor, purulent drainage (infection)

Prevention Protocol (Standard of Care)

  1. Risk assessment: Braden Scale on admission, daily, with condition change
  2. Repositioning: Every 2 hours (bed); every 1 hour (chair); 30° lateral incline
  3. Support surfaces: Pressure-redistributing mattresses, overlays, cushions
  4. Skin care: Clean/dry; pH-balanced cleansers; moisture barriers for incontinence
  5. Nutrition: 30-35 kcal/kg, 1.25-1.5 g protein/kg, supplements if needed
  6. Hydration: 1.5-2L/day unless restricted
  7. Education: Patient/family on repositioning, skin checks, reporting changes

Treatment Principles

  • Pressure relief - Offload affected area completely
  • Wound bed preparation: Debride necrotic tissue (autolytic, enzymatic, surgical)
  • Infection control: Topical antimicrobials (silver, honey); systemic if spreading
  • Moisture balance: Appropriate dressings (foam, hydrocolloid, alginate, hydrogel)
  • Nutritional optimization - Arginine, zinc, vitamin C supplements
  • Multidisciplinary team: Wound nurse, dietitian, PT/OT, physician

Complications

  • Cellulitis, osteomyelitis, septicemia
  • Squamous cell carcinoma (Marjolin's ulcer - chronic wounds)
  • Severe pain, depression, social isolation
  • Prolonged hospitalization, increased mortality

Key Message

Most bed sores are preventable. Systematic risk assessment, consistent repositioning, appropriate support surfaces, and nutritional optimization are the foundation of prevention. Early detection of Stage 1 allows intervention before tissue loss occurs.

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