Introduction

Photo of a woman with her arm around an older woman (Sandor Kacso / Hemera / Thinkstock)

Some people inevitably spend a lot of time in a sitting or lying position. Most of them keep moving and shifting a little, consciously or subconsciously. But people who are extremely weak, paralyzed or unconscious may sit or lie motionless in the same position for a very long time. This puts them at greater risk of developing pressure ulcers (also called bedsores or pressure sores), which are open wounds caused by persistent external pressure against the skin. They can be very painful and usually take a long time to heal.

Causes

Pressure ulcers nearly always develop in places where there are bones right under the skin. This includes the tailbone, heels, hips, shoulder blades, ankles, elbows, ears, and the back of your head.

If your body weight constantly “squashes” your skin in these places when you are sitting or lying, not enough blood can get through to provide oxygen and nutrients. The skin becomes thinner, and it may gradually die over time. This creates an open wound that is especially sensitive when you sit or lie on it.Illustration: Pressure ulcers: Places where they commonly develop while lying on your sideIllustration: Pressure ulcers: Places where they commonly develop while lying on your backPressure ulcers: Places where they commonly develop in people lying down

Illustration: Pressure ulcers: Places where they commonly develop while sitting in a wheelchairIllustration: Pressure ulcers: Places where they commonly develop while sittingPressure ulcers: Places where they commonly develop in people sitting

 

Risk factors

People who are healthy quickly notice pain whenever there is too much pressure on one part of their body. But some health conditions can affect how you feel pain, and certain external factors can make pressure ulcers more likely to occur:

  • People who are paralyzed often do not sense pressure or pain in the parts of their body that are affected.
  • People who have had diabetes for many years sometimes feel less pain and may not notice if there is too much pressure on a part of their body. Diabetes can also affect the flow of blood though the body.
  • Circulation disorders, possibly due to narrowed blood vessels (arteriosclerosis), make it even more difficult for blood to reach vulnerable areas of skin.
  • Malnutrition is an additional risk factor for people who are bedridden. If people hardly have any body fat and drink and eat very little, their skin is thinner, has a poor blood supply, and is not as tough as normal skin.
  • Friction and shear (the forces caused by two layers of skin rubbing against each other) can damage the skin further. This might happen when people who are confined to their bed are moved and their skin rubs against the mattress or sheets. This can cause redness and superficial skin injuries.
  • Skin exposed to urine, feces or sweat for hours is more prone to irritation and damage. Incontinence itself does not cause pressure ulcers, but skin is more likely to become sore in people who are often in wet diapers for longer periods of time.

If someone has already had a pressure ulcer, they are more likely to develop another one in the same place, even after the previous one has healed. This makes it all the more important to try to keep pressure ulcers from developing in the first place.

Effects

Pressure ulcers can be very painful and also emotionally distressing. Open, poorly healing wounds also act as gateways for germs, which may lead to an infection. If germs spread further into the body they may cause blood poisoning (septicemia).

Pressure ulcers that do not heal are also referred to as chronic wounds, and the treatment can take a very long time.

Diagnosis

Some people are able to check their own skin for early signs of pressure ulcers, for example with the help of a mirror. If they have been in a situation where they could hardly move or were not able to move at all for a longer time, they often know the warning signs. People who are too weak to turn around on their own have to rely on help from others, though. This is partly because most of the areas that are at risk are on the back of their body.

Not all wounds or skin injuries will turn into pressure ulcers. Nurses and doctors often use the following classification system to assess the severity of a pressure ulcer

  • Stage I: The skin is reddened, even when no pressure is applied. It may be warmer than usual, but is still intact.
  • Stage II: There is some superficial damage to the skin, in the form of a blister or graze.
  • Stage III: All of the skin layers are damaged and there is a deep wound that may even reach muscle tissue. Some of the skin may have died (necrosis).
  • Stage IV: A large part of the skin is damaged and dead. Muscle and bone tissue may be damaged too.

Prevention

If someone has to sit or lie down without moving for a long time – even if just for a few days – it is important to reduce the pressure on the parts of their body that are most at risk. This is mainly done by regularly shifting and repositioning them. Special supportive surfaces such as special mattresses or pressure-relieving overlays can help to absorb some of the pressure. It is also a good idea to regularly check the more vulnerable areas on their body so that you can react faster if there are any early signs of a pressure ulcer.

It is important to take care to avoid friction and shear forces as much as possible when repositioning and assisting someone. Various nursing techniques can help here.

Learn more

Treatment

As much pressure as possible should be taken off of the pressure ulcer. The most important thing is to stop sitting or lying on the wound. Special positioning aids, special soft mattresses, and regular repositioning and movement help to relieve the pressure.

Sterile wound dressings are usually used to protect the wound and help it to heal. If necessary, the wound is also regularly cleaned and dead tissue removed. The most appropriate treatment will depend on the type and severity of the pressure ulcer.

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Please note that we do not provide individual advice on matters of health. You can read about where to find help and support in Germany in our information “How can I find self-help groups and information centers?”

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