What Are Bedsores?
A bedsore is an area of broken skin the can form when something keeps rubbing or pressing against the skin. Bedsores are also called pressure sores, pressure ulcers or decubitus ulcers. These dangerous skin wounds can develop in a matter of hours and can be painful. Although preventable, bedsores can be extremely difficult to heal, are very vulnerable to infection and can become fatal.
Bedsores can start as patches of redness and, if left untreated, can form blisters or open sores. In severe cases, damage can create a deep crater that exposes muscle or bone. Depending on the severity of the skin damage, the skin may ooze or become swollen, tender, itchy, warm or cold and firm.
Bedsores by the Numbers
$11 million — the total cost for treatment of bedsores in the U.S. annually
2.5 million — the number of U.S. patients who develop bedsores each year
$20,900 to $151,700 — the cost per patient to treat a bedsore
60,000 — the number of patients who die each year due to bedsores
$43,000 — the added cost to a hospital stay brought on by each bedsore
17,000 — the number of lawsuits related to bedsores filed annually in the U.S.
How and Where Bedsores Form
People tend to move frequently, even when asleep, protecting their skin from being injured by pressure. But when a person is immobile, the weight of the person’s body presses the skin against the firm surface of the bed or wheelchair.
This pressure injures skin cells by temporarily cutting off the skin’s blood supply. If the pressure is not relieved, blood will not flow to the skin again, and the skin will start to show symptoms of damage. Pressure does not have to be very intense to cause bedsores.
Areas that are in constant contact with a hard surface, such as a bed or wheelchair, are more likely to develop pressure sores. Parts of the body where skin is in close contact with the bone are the most common places bedsores develop.
In people confined to a bed, bedsores tend to develop on the:
- Back of the head
In people who use a wheelchair, bedsores most commonly form on the:
- Shoulder blade
- Ball of foot
There are several factors that make a person more likely to develop bedsores. Those who are most at risk for bedsores include people who are confined to bed for extended periods of time, use a wheelchair or bedside chair, or are immobile for short periods of time, especially if they are thin or have blood vessel disease or neurological diseases. Being aware of these factors can help family members stay vigilant and help minimize the risk of developing wounds.
Sedentary people — even if only temporarily — have a heightened risk for developing pressure ulcers. Sedentary populations include senior citizens, paralytics and coma patients. People who are in wheelchairs or are confined to bed rest while pregnant, ill or recovering from surgery are also considered sedentary and therefore are at risk for developing sores.
The older skin gets, the thinner and more fragile it becomes. This leaves it susceptible to developing ulcers after too much pressure or tearing due to friction. Because of this, older or frailer people are at increased risk.
People who are severely overweight or obese and sedentary are at a greater risk for developing bedsores because the higher the body weight, the more pressure on the skin when it’s in contact with a hard surface. Obese people with large areas of folded over skin are also at risk of developing bedsores from prolonged friction known as shear. Conversely, those who lose a significant amount of weight have decreased padding between bones and skin, making them more likely to develop bedsores if they become sedentary.
Bladder and Bowel Incontinence
Moisture increases friction between a person’s skin and clothing or sheets, which can lead to bedsores. People who cannot control their bladders are at an increased risk for this occurring. Because many bedsores develop at the base of the spine or on the buttocks, people who cannot control their bowels are often exposed to fecal bacteria. This population is likely to develop severe pressure ulcer infections.
People who are not mentally alert — for reasons including medication, sedation, trauma and illness — typically do not have control over their bodies. They become high-risk for developing bedsores when they do not move themselves, shift regularly or acknowledge when they are in pain.
Similarly, people who cannot feel pain, such as those affected by paralysis, are likely to develop bedsores because they can’t feel the symptoms. Caregivers need to pay extra attention to any signs of bedsores in this population because this population will not be able to detect the signs. Sores that go untreated are more likely to progress into more serious injuries.
Decreased Blood Flow
Some people with chronic illnesses are also more likely to develop complications from bedsores than other populations. The bedsore healing process requires good blood circulation that may be compromised in people with diabetes and hardening arteries, for example.
In general, a bedsore diagnosis involves examining the patient’s skin to determine the size and depth of an ulcer. Doctors look for blood or fluid in the wound and check for signs of infection such as odors, discolored flesh or debris in the wound. They also examine the surrounding tissue for signs that the sore or infection is spreading and look for other sores on the body.
If a doctor determines a person’s bedsore has caused an infection, the doctor may order tests to find out whether the infection has moved into the soft tissues, bones or bloodstream, or to another area of the body. Tests may include a blood test, an x-ray, a magnetic resonance imaging (MRI) scan or a bone scan to look for evidence of a bone infection called osteomyelitis. Doctors may also send tissue or secretions from the bedsore to a laboratory for further examination.
Bedsore Symptoms and Stages
Since 1975, scientists have defined the progression of bedsores in four stages. In 2007, the National Pressure Ulcer Advisory Panel added two new stages to the list after more than five years of research on deep tissue injury. Characteristics of the sores vary with each stage of severity.
Stage I: Non-Blanchable Erythema
Stage I is when the earliest signs of skin damage present. The skin, usually over a bony area, is intact. In patients with white or pale skin tones, the area may be red and does not turn white when touched. For patients with darker skin tones, the area may red, purple or blue and may be more difficult to detect.
If the red area is soft or firm, or warm or cool compared to surrounding skin, it may be an early sign of bedsores. Typically, the area is tender or painful for the patient.
Stage II: Partial Thickness
The skin in the affected area blisters or develops an open sore or cut. The ulcer is shallow, and the area will be pink or red. There is no yellow, brown or black tissue, and no scab or bruising is present.
Stage III: Full Thickness Skin Loss
Any remaining skin in the affected area has deteriorated. The ulcer is deeper, although the depth of the wound varies based on the location of the ulcer. A layer of fat is exposed. Yellow, brown or black tissue or scabs may have developed.
Stage IV: Full Thickness Tissue Loss
The sore has deepened further and now exposes bone, muscle, tendon or joint. Yellow, brown or black tissue or scabs may be present. Tunneling (when an opening underneath the skin is formed) may also occur, which could lead to more tissue damage.
Unstageable Full Thickness or Tissue Loss
The ulcer has deepened past Stage I and II but physicians cannot determine whether the patient is in Stage III or IV because the wound is covered with yellow, brown or black tissue or scabs. To determine the depth of the wound and assess its phase, the doctor must remove the obstructions. The only exception is in the case of dry and intact scabs that exist without redness, which should not be removed because they serve as the body’s natural cover of a wound.
Suspected Deep Tissue Injury
The skin is intact but is a deep purple or maroon color, or a blood-filled blister may exist, which suggests damage of underlying tissue. The area may feel firm or mushy compared to surrounding skin and feels painful to the patient. Deep tissue injury can be difficult to detect in patients with darker skin tones.
Treating bedsores varies based on the stage of the ulcer. Stage I sores, and possibly mild stage II sores, can be treated with preventative strategies. More serious sores may require medication, surgery and other methods to treat. Treatment may also require addressing certain risk factors, such as incontinence, if they can be directly identified as the sole cause of the sores.
Some treatments include:
- Dressing the wounds – Dressings prevent infection, keep wounds clean and are often a way to administer topical antibiotics.
- Removing damaged tissue – Also called debridement, this process involves removing any debris and dead tissue from the sore. Debridement can be accomplished several ways, including using chemical enzymes, pressurized irrigation or surgery.
- Medication – Most infected bedsores cannot heal without antibiotics, which may be applied topically as creams, taken orally as pills or given into the vein.
- Surgery – In some cases, the best way to treat a bedsore is surgically. Typically, this surgery involves relocating a portion of the patient’s muscle and skin to pad the affected bone and cover the open wound.
Severity of the bedsore, the type of treatment and the person’s age, overall health, nutrition and ability to move are all factors that contribute to how long a bedsore lasts. Some bedsores never heal and can be ongoing problems in chronically ill people who suffer from incontinence, the inability to move and circulatory problems. However, a relatively healthy older person who eats well and is able to move may be healed of a Stage II bedsore within one to six weeks. It can take more than six months for a Stage III and Stage IV ulcer to heal.
Complications Related to Bedsores
If a person’s bedsores reach the advance stages, they are likely to experience one or more complications, including various forms of infection and even cancer. Complications from the wounds are more difficult to treat and may even be fatal.
An infection can delay the healing of a bedsore and can easily spread to other parts of the body. If the infection is left unchecked, it can lead to death. Signs of infection include pus draining from the sore, a bad smell, a fever and/or a tender, warm, swollen and red area around the sore.
Several different kinds of infection can occur:
- Cellulitis — an infection of the skin and surrounding tissue
- Bone Infection — an infection that can reduce joint and limb functions
- Joint Infection — an infection that can impact tissue and cartilage
- Blood Poisoning — an infection spread through the blood stream, also known as septicemia and sepsis
- Necrotising Fasciitis — an infection also known as flesh-eating bacteria
- Gas Gangrene — a rare infection that often requires amputation to treat
Untreated bedsores can also lead to the development of squamous cell carcinoma, a type of cancer. This type of skin cancer develops in non-healing wounds. Squamous cell carcinoma is an aggressive disease that typically requires surgery.
Most physicians recommend a regimented preventative strategy to avoid bedsores from developing. Even if signs of skin damage surface, there are steps caregivers can take to prevent areas of redness from becoming full-blown ulcers.
Moving and repositioning the body is a way to prevent the development of bedsores. Repositioning includes regularly turning bedridden patients or regularly repositioning those in wheelchairs. Moving patients can be made easier by using special cushions and mattresses filled with gel, air or water. Patients may also use adjustable beds so they can lie or sleep at different angles, or they may use specialty wheelchairs so they can sit at different angles.
Keeping skin clean, dry and free of bacteria, especially with bladder and bowel incontinence patients, is vital. Preventative skin care measures include drinking plenty of water to ensure the skin is hydrated and doesn’t crack, and using baby powder to keep excessively wet skin dry and to reduce friction. Experts recommend caregivers keep existing bedsores clean and dry by washing with a mild soap and plain water and by using a clean towel to pat the area dry. Avoid irritating antiseptics, hydrogen peroxide, povidone iodine solution or other harsh chemicals to clean or disinfect the skin. Draw moisture away from vulnerable areas by using absorbent pads.
Exercise and Diet
Exercise increases blood flow and speeds up the healing process. Encourage those confined to their beds to try stretches and simple exercises daily. Diet is also important and should include adequate calories, protein, vitamins and minerals. Nutritional supplements may be an option for people who cannot eat enough food.
Dragging a person across bed sheets or leaving crumbs and other particles in the bed can rub and irritate the skin and should be avoided. According to a Harvard Medical School report, it’s better to lift the person or have the person use overhead trapeze to briefly raise his or her body. Sheepskin boots and elbow pads can help to reduce friction on heels and elbows.
Nurses, caregivers and doctors should regularly inspect the skin of a person who is at risk of developing bedsores. If caught in the early stages, the advances of these ulcers can be reversed and the patient can be spared a painful and potentially life-threatening endeavor.
Family members should pay attention to any changes in their loved ones’ behavior, cleanliness and general demeanor. Nursing home residents who have frequent family visits are more likely to receive the care they need from nursing staff.
Studies and Research
The alarming trend of bedsores has caught the attention of many researchers and scientists in recent years. One of the most comprehensive studies of bedsores —the 2004 National Nursing Home Survey — found 11 percent of nursing home residents had bedsores, with stage II sores being the most common. It also revealed that people under 65 years of age were more likely to have ulcers than older patients and that the longer a person’s stay in a nursing home, the more likely he or she was to have an ulcer. The study further found that one in five residents who had a recent weight loss developed ulcers and that 35 percent of bedsore patients with Stage II sores or higher received special wound care.
Another study examined the financial costs of treating a Stage IV bedsore. Of the 19 patients examined, 11 developed pressure ulcers during a hospital stay, and eight had community-acquired ulcers, or ones that developed before hospital admission.The study found it took only one hospital admission to treat hospital-acquired sores, and the average cost of treatment for hospital-acquired sores was estimated at $129,248. Conversely, community-acquired sores took four hospital admissions to treat at an average treatment cost of $124,327.
In a 2011 study, scientists learned it’s 50 times more expensive to treat a bedsore than to prevent one.
|Intervention||Daily Prevention Cost (2009 Dollars)||Daily Treatment Cost for Stage I/II (2009 Dollars)|
A 2016 report by the American Hospital Association, U.S. Department of Health and Human Services and Health Research & Education Trust found the total costs for treatment of pressure ulcers in the U.S. is estimated at $11 billion annually. According to the report, “pressure ulcer incidence rates vary considerably by clinical setting.” Bedsore incidence rates in an acute care setting were between 0.4 and 38 percent. In a long-term care setting, the incidence rates were between 2.2 and 23.9 percent, and they were between 0 and 17 percent for at-home care.
Bedsores and Nursing Home Abuse
If your immobile loved one has been placed in the care of a home nurse or residential facility like a nursing home or assisted living home, it is the staff’s responsibility to prevent bedsores from developing. However, this is often not the case, and research shows people who are admitted to nursing homes are actually more likely than others to develop bedsores.
A 2008 study concluded nursing home residency “is a potent marker for pressure ulcer risk.” Its data revealed 26.2 percent of people admitted to the hospital from a nursing home had pressure ulcers compared with 4.8 percent of people admitted from another living situation who had pressure ulcers.
Bedsores can be the result of nursing home abuse or negligence caused by under-staffing, under-training or several other factors. In spite of national efforts to curb nursing home abuse, it remains a problem for elderly Americans.
Resources for Patients and Their Families
- Browse the National Center on Elder Abuse website. This government organization is tasked with educating and preventing elder abuse. Its resources may help you determine if your loved one was abused and guide you on next steps.
- Read through resources from the U.S. Senate Special Committee on Aging. These resources have been vetted by the U.S. government and are a good starting point.
- Research nursing homes before choosing one for your loved one. Medicare.gov provides a “Nursing Home Compare” feature that is a database of all government-collected information on Medicare- or Medicaid-certified nursing homes.
- Read the Federal Nursing Home Reform Act. Passed in 1987, this legislation outlines a nursing home resident’s rights. If any of these rules have been violated, you may have grounds to sue.
- Call an attorney. Many attorneys specialize in nursing home abuse and bedsore cases and can help you determine whether your family can be awarded compensation for your pain and suffering.
To report nursing home abuse, call 911 or contact the National Adult Protective Services Association.
- Mayo Clinic Staff. (2014, December 13). Bedsores (pressure sores) - Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/bedsores/basics/definition/con-20030848
- NPUAP pressure ulcer stages/categories | The National Pressure Ulcer Advisory Panel. (n.d.). Retrieved from http://www.npuap.org/
- Bed sores and pressure sores - Nursing Home Abuse Center. (n.d.). Retrieved from http://www.nursinghomeabusecenter.org/types-of-abuse/bedsores/
- Franks, J. (2015, April 9). Bedsores: Risk factors & prevention. Retrieved from http://www.aplaceformom.com/senior-care-resources/articles/bedsores
- Pressure ulcers - Complications - NHS Choices. (2014, October 9). Retrieved from http://www.nhs.uk/Conditions/Pressure-ulcers/Pages/Complications.aspx
- FamilyDoctor.org Editorial Staff. (2012, January). Pressure sores | Overview. Retrieved from http://familydoctor.org/familydoctor/en/diseases-conditions/pressure-sores.printerview.all.html
- Park-Lee, E., & Caffrey, C. (2009, February). Pressure ulcers among nursing home residents: United States, 2004. Retrieved from http://www.cdc.gov/nchs/products/databriefs/db14.htm
- Keelaghan, E., Margolis, D., Zhan, M., & Baumgarten, M. (2010, March 16). Prevalence of pressure ulcers on hospital admission among nursing home residents transferred to the hospital. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2839543/
- Agency for Healthcare Research and Quality. (2014, October). Preventing pressure ulcers in hospitals. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html
- Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., … Vladeck, B. (2011, October 1). High cost of Stage IV pressure ulcers. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950802/
- Padula, W., Mishra, M., Makic, M., & Sullivan, P. (2011, April). Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. - PubMed - NCBI. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21368685
- Harvard Health Publications. (2014, October). Bedsores (Decubitus Ulcers). Retrieved from http://www.health.harvard.edu/diseases-and-conditions/bedsores-decubitus-ulcers-
- Health Research & Educational Trust. (2016). Hospital Acquired Pressure Ulcers (HAPU). Retrieved from http://www.hret-hiin.org/Resources/pu/16/HRETHENPRU_ChangePackage.pdf