Pressure Ulcer

What is a pressure ulcer?

A pressure ulcer is an injury to the skin or tissue over a bony area. A pressure ulcer is also called a pressure sore, bedsore, or decubitus ulcer. Pressure ulcers may form over the bony areas on the back, hips, heels, buttocks, or ankles.

What causes pressure ulcers?

  • Continuous pressure: Pressure happens when you sit or lie on a bony area for too long. Pressure on bony areas slows down or stops the blood from flowing to the skin. Pressure may hurt the skin and the layers of tissue underneath it. This may cause the tissue to become damaged, or even die. Pressure may begin to cause damage to your skin and tissue about two hours after staying in the same position.

  • Shearing or friction: Shearing or friction happens when fragile (delicate) skin is dragged across a surface, such as sheets. This may cause your skin to tear or a blister to form. Sliding up or down in bed or moving from the bed to a chair may tear fragile skin. Muscle spasms may cause your arms or legs to jerk and rub the sheets, causing tears in your skin.

What increases my risk for a pressure ulcer?

  • Age: You may be at risk if you are over 65 years old.

  • Incontinence: Incontinence occurs when you cannot control when you urinate or have a bowel movements. Incontinence causes you to leak urine or stool. You may be at risk for pressure ulcers if you sit or lie in urine or stool.

  • Malnutrition and dehydration: Malnutrition means that your body is not getting enough calories and nutrients, such as protein and fat. Dehydration means that your body is not getting enough healthy liquids, such as water. Malnutrition and dehydration may cause your skin to be injured more easily. You may have less padding (tissue and fat) over bony areas of your body. Less padding may increase the pressure over a bony area.

  • Lack of movement: Staying in a chair or in bed most, or all, of the time puts pressure on your bony areas. Increased pressure for long periods of time increases your chance of getting a pressure ulcer. Medical conditions that may lead to a lack of movement include a spinal cord injury, a stroke, or a hip fracture.

  • Numbness: Numbness is when you have decreased or lost feeling in an area of your body. Your skin may become damaged without your knowing it. Medical conditions that may cause a loss of feeling include multiple sclerosis or nerve damage from diabetes.

  • Previous pressure ulcer: You may have a higher chance of getting a pressure ulcer if you have had a pressure ulcer before.

  • Smoking: Smoking harms your body in many ways. Smoking increases your chance of getting a pressure ulcer. You are more likely to have heart disease, lung disease, cancer, and other health problems if you smoke. If you have a pressure ulcer, smoking may keep a pressure ulcer from healing.

What are the stages of a pressure ulcer?

Caregivers use stages to describe how severe (bad) a pressure ulcer is. Each stage of pressure ulcers will have different signs and symptoms. The stages of a pressure ulcer are as follows:

  • Deep tissue injury: At this stage, the skin is not broken. You may see purple or red skin, or a blister, over a bony area, such as your hip or heel. Your skin may feel warm, spongy, or tight when you touch it.

  • Stage 1: At this stage, your skin is not broken, but it may itch or hurt. Your skin may feel warm, spongy, or tight when you touch it. The skin may stay red for more than an hour after pressure is removed from the bony area.

  • Stage 2: At this stage, the skin has broken. You may have an open sore and the area around it may be red and raw. Your skin may sink inward and look shiny or dry.

  • Stage 3: When the pressure ulcer gets to this stage, the tissue below your skin is damaged. The area looks like a deep crater, or bowl-shaped hole. There may be more damage hidden under the skin than what you can see.

  • Stage 4: At this stage, the sore is very deep and your tendons, muscle, and bone may be damaged. You may be able to see the tendons, muscle, and bone in the wound. Tendons are strong tissues that connect muscle to bone.

  • Unstageable: This means it is hard for healthcare providers to see what stage your pressure ulcer is in. This is normally because there is a lot of dead tissue or scabbing in the wound.

How is a pressure ulcer diagnosed?

Your healthcare provider will ask about your pressure ulcer and examine you. He may ask when your pressure ulcer started and if it is getting bigger or changing color. He may ask if you have pain or numbness over any bony areas. He may ask if you have other health problems, such as diabetes. Your healthcare provider may ask how you care for your skin at home. You may also need the following tests:

  • Blood tests: You may need blood tests to check for infection or other medical conditions. The blood can be taken from a blood vessel in your hand, arm, or the bend in your elbow. It is tested to see how your body is doing. It can give your healthcare providers more information about your health condition. You may need to have blood drawn more than once.

  • X-ray: An x-ray is a picture taken of your bones and tissues. Your healthcare provider may want x-rays of the bone under your pressure ulcer. He may want to check the shape of your bone and make sure it is in the correct position.

  • Magnetic resonance imaging: This test is called an MRI. During the MRI, pictures are taken of the bone under your pressure ulcer. Caregivers are looking for infection in the bone. You will need to lie still during an MRI. Never enter the MRI room with any metal objects. This can cause serious injury. Tell your healthcare provider if you have any metal implants in your body.

  • Bone scan: This is a test to look at your bones. You are given a small amount of dye through an IV, and pictures of your bones are taken. An IV is a small tube put in your vein to give medicines and liquids. Caregivers can look at the pictures for broken bones, infections, and other problems.

  • Ultrasound: An ultrasound is a test that looks inside of your body. Sound waves are used to show pictures of your tissues on a TV-like screen. An ultrasound helps healthcare providers see if your pressure ulcer is getting enough blood and nutrients.

  • Wound biopsy: A biopsy is when healthcare providers take a small sample of tissue from inside your pressure ulcer. If you have an infection, a biopsy may tell healthcare providers which germ is causing the infection. This will help your healthcare provider know what the best treatment is to give you.

  • Bone biopsy: Stage four and unstageable ulcers are very deep and may involve your bone. If your healthcare provider thinks you have an infection in your bone, he might take a bone biopsy. This is when he cuts a very small piece of your bone to check for infection.

How is a pressure ulcer treated?

Treatment for a deep tissue injury or stage one pressure ulcer is done to prevent the skin from breaking. This is done by changing your position often and keeping your skin clean and dry. You may also need the following treatments depending on the stage of your pressure ulcer:

  • Dressing changes: Caregivers may want to protect the wound with a dressing. There are many different kinds of dressings. Your healthcare provider will pick the best kind of dressing for your ulcer. Dressing changes may include cleaning the wound with saline (saltwater). If your wound is deep, gauze that is wet with saline may be used to fill the wound. This is called packing the wound. A clean, dry dressing is placed over the packed wound to keep the skin dry. When the gauze dries, it is taken out and replaced with fresh, wet gauze.

  • Medicines:

    • Antibiotics: Antibiotics are germ-killing medicines used to treat an infection. Starting in stage two, you have a higher chance of infection because the skin is broken. Your healthcare provider may use a special cream to help prevent infection. This cream will be put on the skin with each dressing change. If you have a stage three or higher pressure ulcer, you may need IV antibiotics. Ask your healthcare provider for more information on antibiotics.

    • Pain medicine: Dressing changes may be painful. Ask your healthcare provider for pain medicine if you have pain with dressing changes.

  • Debridement: Caregivers may want to do a debridement if you may have dead tissue at the bottom of the wound crater. This dead tissue may keep the wound from healing. Debridement is when healthcare providers clean out the dead tissue so that healthy tissue can form. Ask your healthcare provider for more information on debridement.

  • Vacuum-assisted therapy: This is a machine that works like a gentle vacuum. It attaches to a special dressing that covers your ulcer. The vacuum gently pulls the dead tissue from your wound. This causes healthy tissue to grow in its place. Ask your healthcare provider for more information on vacuum-assisted therapy.

  • Surgery: You may need a flap closure. This is surgery to close the wound. A skin flap (piece of skin) is usually taken from an area close to the wound. One end of the skin flap often remains attached while the other end of the skin is moved to cover your wound. The skin flap is secured with stitches or staples. Ask your healthcare provider for more information about flap closure.

What can I do to help my pressure ulcer heal?

  • Eat a healthy diet: A diet high in protein may help your pressure ulcer heal. This includes foods, such as meat, chicken, beans, milk, yogurt, and cheese. Nutrition shakes may also give you extra calories and protein if you have trouble eating or are underweight. Drink at least eight 8 ounce cups of healthy liquids each day, unless your healthcare provider tells you not to. Healthy liquids include water, milk, and juice. Ask your healthcare provider for more information about what kind of diet is right for you.

  • Change your position often: Change your position every two hours if you are in a bed all day. Change your position every hour if you are in a wheelchair all day. Set a kitchen timer to help remind you when it is time to turn. Keep a written turning schedule to help you remember to turn.

  • Keep your skin clean, dry, and moisturized: Use mild soaps and warm (not hot) water to gently clean your skin. Do not rub hard or use force when washing your skin. Avoid soaps and other products with alcohol in them, because they can dry out your skin. Use a towel to gently pat your skin dry after cleaning it. Do not rub your skin when drying it with a towel. Put lotion or a moisturizer on your skin often.

  • Protect the skin over bony areas: Do not rest directly on your hipbone when lying on your side. Lean back into a pillow or foam wedge behind your back when lying on your side. This may decrease the pressure put directly on your hipbone. Use pillows or foam wedges to keep bony areas from touching one another. Put a pillow or foam wedge between your knees to keep them from pressing on one another. Keep your heels from touching the bed when lying on your back. Do this by putting a foam pad or a pillow under your legs from mid-calf to ankle. The pad or pillow should raise the heels so that they are not touching the bed.

  • Use special equipment and pads: A draw sheet or large pad under you may help others move you up in bed. An overhead trapeze can help you change positions in bed. Special mattresses and overlays may help decrease the risk of pressure ulcers. Examples include a foam mattress pad, or special air or water mattresses. Ask your healthcare provider for more information about special equipment that may be right for you and how to use it.

  • Lifestyle changes: Avoid drinking alcohol , because it may cause dehydration (not enough fluid in the body). Alcohol is found in beer, wine, whiskey, and other adult drinks. Smoking tobacco can damage your skin and slow wound healing. If you smoke, it is never too late to quit. Ask your healthcare provider for information if you need help quitting smoking.

When should I call my healthcare provider?

  • You have a fever.

  • You have green or yellow drainage or a bad smell coming from your pressure ulcer.

  • You are having trouble keeping your skin dry because you are leaking urine or stool.

  • You have questions or concerns about your pressure ulcer or care.

When should I seek immediate care or call 911?

  • You have sudden trouble breathing.

  • You heart is beating faster than it normally does.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

© 2014 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics.

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