Bedsores 101: Pressure Ulcer Stages, Signs, Treatment & Prevention

Bedsores, or pressure ulcers, is the most common ulcer in Singapore, occurring in 183 per 100,000 Singaporeans. Chronic wounds in general, are also on a rising trend among people residing in Singapore aged 80 and above.

Since the burden of wounds is expected to heighten as the population ages, it can be helpful to find out more about pressure ulcers, their signs and symptoms, treatment, and prevention.

What is a Pressure Ulcer?

A pressure ulcer or bedsore is an injury to the skin and underlying tissues, particularly on “bony” areas such as the tailbone, hips, ankles, and heels; they occur due to prolonged pressure on the affected area.

The other terms people use to refer to bedsores are pressure sores, pressure injuries, and decubitus ulcers.

Generally, people who develop bedsores have conditions that limit their ability to move (unconsciousness, immobility, etc.). This means that they spend a significant amount of time lying in bed or sitting on a chair, which may limit the blood flow to certain areas of their body. People who wear a cast for a long time and those with inadequate capacity to sense pain are also at risk of experiencing bedsores.

Another important thing to note is this: some people develop bedsores in a matter of hours, not days. Furthermore, while many bedsores get better with treatment, others do not completely heal.

What Causes Pressure Ulcers?

Pressure ulcers occur because the affected skin and tissues underneath it don’t receive enough blood supply. This is a concern because blood carries oxygen and other nutrients that keep our cells healthy. Without an adequate blood supply, the tissues can become damaged and eventually diet.

Three factors contribute to the development of bedsores; they are:

1. Pressure

Constant and significant pressure can impede blood flow to any part of the body. Think back to the times when you felt a tingling or numbing sensation after sitting down for too long. That sensation happened because the lack of movement affected your blood circulation.

People with conditions that limit their ability to move often experience bedsores on “bony” areas or those not well-padded by muscle or fat. Examples include: 

• Back or sides of the head
• The rim of the ears
• Shoulder blades
• Spine
• Tailbone
• Elbows
• Hips
• Back or sides of the knees
• Ankles
• Heels

2. Friction

Another contributing factor is friction, the mechanical force occurring when our skin rubs against clothes, bedsheets, or linens. It doesn’t involve pressure, but repeated friction can make the skin (and the underlying tissues) more vulnerable to damage, especially if the area experiencing friction is often moist.

3. Shearing

Last on our list of factors that contribute to the development of a bedsore is shearing, a mechanical force that happens when two surfaces move in the opposite direction.

In pressure ulcers, the “two surfaces” we refer to are the bones and the skin. Consider a patient in bed whose head is in a raised position. The force of gravity pulls the skeleton down, but because of friction, the surface of the skin remains attached to the bed. As a result, the blood vessels between the bones and skin become compressed and blood flow is interrupted.

Risk Factors for Bedsores

Many cases of bedsores occur in seniors because their skin is thinner and more vulnerable, but the following factors also increase someone’s risk of developing a pressure ulcer:

• Immobility – for instance, people who experienced paralysis due to stroke.
• Impaired ability to feel or respond to pain – this can happen to people with nerve damage due to diabetes.
• Incontinence – skin exposed to urine or faeces is more vulnerable to pressure sores.
• Problems in circulation – someone who has blood flow problems is also at risk.
• Malnutrition – undernutrition can affect the skin’s integrity; likewise, being obese means the tiny blood vessels receive added pressure which can impede blood flow. When malnutrition occurs with other factors like immobility, the risk of developing bedsores increases.
• Smoking – cigarette smoking damages the blood vessels; combined with reduced mobility, smoking also increases pressure ulcer risk.

Stages of Pressure Ulcers

Different pressure ulcer stages exhibit various signs and require diverse interventions. Below are the different pressure sore stages, their symptoms, and the kind of care required.

Stage 1 Pressure Ulcer

Individuals with stage 1 pressure ulcer do not have broken skin; but the affected area looks discoloured (blue, red, or black). The area may also present a different temperature and texture from the surrounding area.

Intervention:

If you see stage 1 pressure ulcer, the following care instructions will help:

• Remove pressure from the area. One of the best ways to do this is to change position.
• Inspect for other contributing factors and remove them where possible.
• Wash the area with a gentle cleanser and pat it dry.
• Stay hydrated and ensure proper nutrition with vitamins and minerals necessary for wound healing (vitamin C, iron, zinc, etc.)
• Continue inspecting the area twice daily.
• Contact your healthcare provider right away if the area does not show signs of improvement after 2 to 3 days.

Stage 2 Pressure Ulcer

For stage 2 pressure ulcers, the topmost layer of the skin, called the epidermis, is already broken, resulting in an open sore, scrape, or blister. There is pain and the area around the wound looks discoloured.

Intervention:

• Follow the steps for stage 1 pressure ulcer care, especially the removal of any pressure.
• Next, call your healthcare provider right away because an open wound may require different care or a specific kind of medication.
• Generally, clean the wound with a saline solution and cover it with a bandage to retain moisture while keeping the surrounding area dry. A bandage also helps protect it against infection.

Stage 3 Pressure Ulcer

Stage 3 pressure ulcer affects the dermis, the layer underneath the epidermis. The wound may or may not extend into the deeper layers, but the bones and tendons are not affected yet. Many cases of stage 3 bedsores have a “crater-like” appearance.

Intervention:

• Call your healthcare provider right away to receive instructions on proper wound care.
• Look for signs of infection, including leaking pus or greenish discharge, redness, odor, and fever. Report these symptoms to the doctor as well.
• Ask the doctor about a special, pressure-relieving mattress.

Stage 4 Pressure Ulcer

This is the last of our pressure ulcer stages. Stage 4 bedsore is extensive, often involving a large, deep, crater sore. At this point, the wound may be deep enough to affect the tendons and bones. There might also be necrosis or tissue death involved.

Intervention:

• Remove any pressure and contact a doctor right away as stage 4 bedsores might require wound debridement (removal of dead tissues) or surgery which uses a pad of muscle or tissues from other body parts to “cover” the sore.

Reminder

In cases where the wound has a full-thickness tissue loss and its base is covered with eschar or slough, the pressure ulcer staging no longer applies; we then say that the bedsore is unstageable. Slough is a wet material that can be yellow, tan, brown, or grey. Eschar is dead tissue that is usually brown or black.

Treatment and Care for Pressure Sores

Interventions for pressure sores, regardless of stages, should be unique to the individual. This is because even two people with the same bedsore stage may exhibit different symptoms.

Corresponding to the stage, doctors recommend the following treatment strategies:

• Position changes to remove the pressure
• Use of special mattresses
• Healthy, balanced nutrition
• Wound cleaning and bandaging for open wounds (stage 2 through 3) — note that the individual may also need topical or oral medicines
• Wound debridement or removal of dead tissues; only trained healthcare persons can do this
• Surgery to “patch” the wound using a pad of muscle or fat tissues from another part of the body

Potential Complications of Untreated Bedsores

Left untreated, the following complications may occur:

• Sepsis, or severe infection that has already spread in the bloodstream
• Cellulitis or swelling and inflammation of the involved tissues
• Infections affecting the bones or joints
• Abscess or the collection of pus
• Squamous carcinoma, a type of cancer

Training for Pressure Ulcer Prevention

Because of the gravity of the potential complications, bedsores prevention should take priority. In the healthcare facilities, staffs undergo pressure ulcer prevention training, which generally consists of:

• Position changes, which helps shift weight and remove the pressure. Patients who have enough body strength should continue lifting themselves from time to time. Those who have limited ability should receive help.
• Use of special mattresses and wheelchairs that help relieve pressure.
• Prevention of shearing force by keeping the head raised at only a 30-degree angle.
• Inspecting the skin regularly for signs of developing bedsores.
• Skincare, which includes keeping the skin clean and dry. The doctor might also prescribe barrier creams to protect the skin from elements like urine and faeces; likewise, the patient might need an ostomy or urinary catheter insertion. Additionally, watch out for things that may irritate the skin, such as unchanged linens and buttons.

Are You Worried About Bedsores?

Do you need help with bedsore prevention training? Our nurses here at Homage can help you. They can give you a visit at home and teach you strategies to reduce your or your family member’s risk of developing decubitus ulcers.

If you notice signs of stage 2 pressure ulcers, talking to a healthcare provider is necessary. That’s because open wounds require personalised care.