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Pressure sores on heels pictures: Bedsores (Pressure Ulcers) in Adults: Condition, Treatments, and Pictures – Overview


Bedsores (Pressure Ulcers) in Adults: Condition, Treatments, and Pictures – Overview


Information for

caption goes here…

Images of Pressure Ulcer (Decubitus Ulcer)


Bedsores (pressure ulcers), also known as pressure sores or decubitus ulcers, result from prolonged pressure that cuts off the blood supply to the skin, causing the skin and other tissue to die. The damage may occur in as little time as 12 hours of pressure, but it might not be noticed until days later when the skin begins to break down. The skin is especially likely to develop pressure sores if it is exposed to rubbing (friction) and moving the skin in one direction and the body in another (shear), as in sliding down when the bed head is raised. Dampness (such as from perspiration or incontinence) makes the skin even more liable to develop pressure sores.

Who’s at risk?

People who cannot move themselves are at the greatest risk of getting bedsores, including people with:

  • Spinal cord injury
  • Paralysis
  • Strokes
  • Nerve (neurologic) disease
  • Decreased mental awareness

Most bedsores occur in older people (over the age of 70), as the skin of older people may be thinner and may heal more slowly.

People in nursing homes and hospitalized people (particularly for hip fracture or intensive care) develop bedsores more commonly.

Smokers and people who do not get good nutrition (malnourished or undernourished), have incontinence (problems with bladder or bowel control), diabetes, or problems with blood flow (circulation) also have increased risk.

Signs and Symptoms

A bedsore appears first as a reddened area of skin, which then starts to break down to form an open, raw, oozing wound.

Bedsores occur at areas of abnormal pressure on the body:

  • In a wheelchair, this is usually the tailbone (coccyx) or buttocks area, shoulder blades, spine, or backs of the arms or legs.
  • In a bed, they may occur on the back of the head, ears, shoulder blades, hips, lower back, tailbone, or the backs or sides of the knees, elbows, ankles, or toes.

The pain level associated with bedsores depends on whether or not there is feeling in the area.

Bedsores occur in stages:

  • Stage 1 has unbroken, but pink or ashen (in darker skin) discoloration with perhaps slight itch or tenderness.
  • Stage 2 has red, swollen skin with a blister or open areas.
  • Stage 3 has a crater-like ulcer extending deeper into the skin.
  • Stage 4 extends to deep fat, muscle, or bone and may have a thick black scab (eschar).

Self-Care Guidelines

Do not attempt self-care for any ulcer beyond stage 2 in appearance.

In the early stages (1 and 2) of bedsores, the area may heal with relief of pressure and by applying care to the affected skin.

A good diet will aid skin healing, especially by taking in enough vitamin C and zinc, which are available as supplements.

For effective skin care:

  • If the skin is not broken, gently wash the area with a mild soap and water.
  • Clean open sores on the skin with salt water (saline, which can be made by boiling 1 quart of water with 1 teaspoon of salt for 5 minutes and kept cooled in a sterile container).
  • Apply a thin layer of petroleum jelly (Vaseline®) and then cover with a soft gauze dressing.
  • Be sure to keep urine and stool away from affected areas.

To relieve pressure:

  • Change positions often (every 15 minutes in a chair and every 2 hours in a bed).
  • Use special soft materials or supports (pads, cushions, and mattresses) to reduce pressure against the skin.

When to Seek Medical Care

If a stage 2 bedsore does not begin to heal in a few days, or if the sore is at stage 3 or above, seek medical advice.

Get immediate care if you notice signs of infection (fever, spreading redness, swelling, or pus).

Treatments Your Physician May Prescribe

In addition to self-care, your doctor might prescribe special pads or mattresses. Special dressings may be used, and whirlpool baths or surgery may be recommended to remove dead tissue. Infection requires antibiotic treatment. Sometimes deep wounds may require surgery to restore the tissue. Experimental work is now being done using honey preparations, high-pressure (hyperbaric) oxygen, and application of chemicals that stimulate cell growth (growth factors).

Trusted Links

MedlinePlus: Pressure SoresClinical Information and Differential Diagnosis of Pressure Ulcer (Decubitus Ulcer)


Bolognia, Jean L., ed. Dermatology, pp.1645-1648. New York: Mosby, 2003.

Freedberg, Irwin M., ed. Fitzpatrick’s Dermatology in General Medicine. 6th ed. pp.1256, 1261-1263. New York: McGraw-Hill, 2003.

Bedsores (Pressure Ulcers) in Adults: Condition, Treatments, and Pictures – Overview


Information for

caption goes here…

Images of Pressure Ulcer (Decubitus Ulcer)


Bedsores (pressure ulcers), also known as pressure sores or decubitus ulcers, result from prolonged pressure that cuts off the blood supply to the skin, causing the skin and other tissue to die. The damage may occur in as little time as 12 hours of pressure, but it might not be noticed until days later when the skin begins to break down. The skin is especially likely to develop pressure sores if it is exposed to rubbing (friction) and moving the skin in one direction and the body in another (shear), as in sliding down when the bed head is raised. Dampness (such as from perspiration or incontinence) makes the skin even more liable to develop pressure sores.

Who’s at risk?

People who cannot move themselves are at the greatest risk of getting bedsores, including people with:

  • Spinal cord injury
  • Paralysis
  • Strokes
  • Nerve (neurologic) disease
  • Decreased mental awareness

Most bedsores occur in older people (over the age of 70), as the skin of older people may be thinner and may heal more slowly.

People in nursing homes and hospitalized people (particularly for hip fracture or intensive care) develop bedsores more commonly.

Smokers and people who do not get good nutrition (malnourished or undernourished), have incontinence (problems with bladder or bowel control), diabetes, or problems with blood flow (circulation) also have increased risk.

Signs and Symptoms

A bedsore appears first as a reddened area of skin, which then starts to break down to form an open, raw, oozing wound.

Bedsores occur at areas of abnormal pressure on the body:

  • In a wheelchair, this is usually the tailbone (coccyx) or buttocks area, shoulder blades, spine, or backs of the arms or legs.
  • In a bed, they may occur on the back of the head, ears, shoulder blades, hips, lower back, tailbone, or the backs or sides of the knees, elbows, ankles, or toes.

The pain level associated with bedsores depends on whether or not there is feeling in the area.

Bedsores occur in stages:

  • Stage 1 has unbroken, but pink or ashen (in darker skin) discoloration with perhaps slight itch or tenderness.
  • Stage 2 has red, swollen skin with a blister or open areas.
  • Stage 3 has a crater-like ulcer extending deeper into the skin.
  • Stage 4 extends to deep fat, muscle, or bone and may have a thick black scab (eschar).

Self-Care Guidelines

Do not attempt self-care for any ulcer beyond stage 2 in appearance.

In the early stages (1 and 2) of bedsores, the area may heal with relief of pressure and by applying care to the affected skin.

A good diet will aid skin healing, especially by taking in enough vitamin C and zinc, which are available as supplements.

For effective skin care:

  • If the skin is not broken, gently wash the area with a mild soap and water.
  • Clean open sores on the skin with salt water (saline, which can be made by boiling 1 quart of water with 1 teaspoon of salt for 5 minutes and kept cooled in a sterile container).
  • Apply a thin layer of petroleum jelly (Vaseline®) and then cover with a soft gauze dressing.
  • Be sure to keep urine and stool away from affected areas.

To relieve pressure:

  • Change positions often (every 15 minutes in a chair and every 2 hours in a bed).
  • Use special soft materials or supports (pads, cushions, and mattresses) to reduce pressure against the skin.

When to Seek Medical Care

If a stage 2 bedsore does not begin to heal in a few days, or if the sore is at stage 3 or above, seek medical advice.

Get immediate care if you notice signs of infection (fever, spreading redness, swelling, or pus).

Treatments Your Physician May Prescribe

In addition to self-care, your doctor might prescribe special pads or mattresses. Special dressings may be used, and whirlpool baths or surgery may be recommended to remove dead tissue. Infection requires antibiotic treatment. Sometimes deep wounds may require surgery to restore the tissue. Experimental work is now being done using honey preparations, high-pressure (hyperbaric) oxygen, and application of chemicals that stimulate cell growth (growth factors).

Trusted Links

MedlinePlus: Pressure SoresClinical Information and Differential Diagnosis of Pressure Ulcer (Decubitus Ulcer)


Bolognia, Jean L., ed. Dermatology, pp.1645-1648. New York: Mosby, 2003.

Freedberg, Irwin M., ed. Fitzpatrick’s Dermatology in General Medicine. 6th ed. pp.1256, 1261-1263. New York: McGraw-Hill, 2003.

Stages of Pressure Sores: Bed Sore Staging 1-4

You may know pressure sores by their more common name: bed sores. They happen when you lie or sit in one position too long and the weight of your body against the surface of the bed or chair cuts off blood supply. You might get them if you’re on bed rest or in a wheelchair.

Your doctor may talk about the “stage” of your pressure sores. The stages are based on how deep the sores are, which can affect their treatment.

If found early, there’s a good chance these sores will heal in a few days, with little fuss or pain. Without treatment, they can get worse.

You’ll know they’re better when the sore gets smaller and pink tissue shows up along the sides.

Stage 1

This is the mildest stage. These pressure sores only affect the upper layer of your skin. 

Symptoms: Pain, burning, or itching are common symptoms. The spot may also feel different from the surrounding skin: firmer or softer, warmer or cooler.

You may notice a red area on your skin. If you have darker skin, the discolored area may be harder to see. The spot doesn’t get lighter when you press on it, or even 10 to 30 minutes after you stop pressing. This means less blood is getting to the area.

What to do: The first and most important thing to do with any pressure sore is to stop the pressure. Change your position or use foam pads, pillows, or mattresses.

If you spend a lot of time in bed, try to move at least once every 2 hours. If you’re sitting, move every 15 minutes. You may need someone to help you.

Wash the sore with mild soap and water and dry it gently.

It may help to eat a diet high in protein, vitamins A and C, and the minerals iron and zinc. These are all good for your skin. Also, drink plenty of water.

Recovery time: A Stage 1 pressure sore may go away in as little as 2 or 3 days. If it hasn’t, call your doctor.

Stage 2

This happens when the sore digs deeper below the surface of your skin.

Symptoms: Your skin is broken, leaves an open wound, or looks like a pus-filled blister.

The area is swollen, warm, and/or red. The sore may ooze clear fluid or pus. And it’s painful.

What to do: Follow the same steps for Stage 1. You should also clean the wound with water or a salt-water solution and dry it gently. This may hurt, so ask your doctor if you should take a pain reliever 30 to 60 minutes before cleaning.

Keep the sore covered with a see-through dressing or moist gauze. If you see signs of an infection (such as pus, fever, or redness), tell your doctor.

Recovery time: A Stage 2 pressure sore should get better in 3 days to 3 weeks.

Stage 3

These sores have gone through the second layer of skin into the fat tissue.

Symptoms: The sore looks like a crater and may have a bad odor. It may show signs of infection: red edges, pus, odor, heat, and/or drainage. The tissue in or around the sore is black if it has died.

What to do: Stage 3 sores will need more care. Talk to your doctor. They may remove any dead tissue and prescribe antibiotics to fight infection. You may also be able to get a special bed or mattress through your insurance.

Recovery time: A Stage 3 pressure sore will take at least one month, and up to 4 months, to heal.

Stage 4

These sores are the most serious. Some may even affect your muscles and ligaments.

Symptoms: The sore is deep and big. Skin has turned black and shows signs of infection — red edges, pus, odor, heat, and/or drainage. You may be able to see tendons, muscles, and bone.

What to do: Tell your doctor right away. These wounds need immediate attention, and you may need surgery.

Recovery time: A Stage 4 pressure sore could take anywhere from 3 months or much longer, even years, to heal.

Other Stages

In addition to the 4 main stages for bed sores, there are 2 others:

“Unstageable” is when you can’t see the bottom of the sore, so you don’t know how deep it is. Your doctor can only stage it once it’s cleaned out.

“Suspected Deep Tissue Injury” (SDTI). This is when the surface of the skin looks like a Stage 1 or 2 sore, but underneath the surface it’s a Stage 3 or 4.

Pressure ulcers (pressure sores) – NHS

Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin.

They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time.

Symptoms of pressure ulcers

Pressure ulcers can affect any part of the body that’s put under pressure. They’re most common on bony parts of the body, such as the heels, elbows, hips and base of the spine.

They often develop gradually, but can sometimes form in a few hours.

Early symptoms

Early symptoms of a pressure ulcer include:

  • part of the skin becoming discoloured – people with pale skin tend to get red patches, while people with dark skin tend to get purple or blue patches
  • discoloured patches not turning white when pressed
  • a patch of skin that feels warm, spongy or hard
  • pain or itchiness in the affected area

A doctor or nurse may call a pressure ulcer at this stage a category 1 pressure ulcer.

Later symptoms

The skin may not be broken at first, but if the pressure ulcer gets worse, it can form:

  • an open wound or blister – a category 2 pressure ulcer
  • a deep wound that reaches the deeper layers of the skin – a category 3 pressure ulcer
  • a very deep wound that may reach the muscle and bone – a category 4 pressure ulcer

When to get medical advice

If you’re in hospital or a care home, tell your healthcare team as soon as possible if you develop symptoms of a pressure ulcer. It’ll probably continue to get worse if nothing is done about it.

You should be regularly monitored and offered advice and treatment to reduce the risk of pressure ulcers, but sometimes they can develop even with the highest standards of care.

If you’re recovering from illness or surgery at home, or you’re caring for someone confined to bed or a wheelchair, contact your GP surgery if you think you or the person you’re caring for might have a pressure ulcer.

Get medical advice immediately if there is: 

  • red, swollen skin
  • pus coming from the pressure ulcer or wound
  • cold skin and a fast heartbeat
  • severe or worsening pain
  • a high temperature

These symptoms could be a sign of a serious infection that needs to be treated as soon as possible.

Treatments for pressure ulcers

Treatments for pressure ulcers depend on how severe they are.

For some people, they’re an inconvenience that needs basic nursing care. For others, they can be serious and lead to life-threatening complications, such as blood poisoning.

Ways to stop pressure ulcers getting worse and help them heal include:

  • applying dressings that speed up the healing process and may help to relieve pressure
  • moving and regularly changing your position
  • using specially designed static foam mattresses or cushions, or dynamic mattresses and cushions that have a pump to provide a constant flow of air
  • eating a healthy, balanced diet
  • a procedure to clean the wound and remove damaged tissue (debridement)

Surgery to remove damaged tissue and close the wound is sometimes used in the most serious cases.

Read more about the treatments for pressure ulcers.

Who’s most at risk of getting pressure ulcers

Anyone can get a pressure ulcer, but the following things can make them more likely to form:

Preventing pressure ulcers

It can be difficult to completely prevent pressure ulcers, but there are some things you or your care team can do to reduce the risk.

These include:

  • regularly changing your position – if you’re unable to change position yourself, a relative or carer will need to help you
  • checking your skin every day for early signs and symptoms of pressure ulcers – this will be done by your care team if you’re in a hospital or care home
  • having a healthy, balanced diet that contains enough protein and a good variety of vitamins and minerals – if you’re concerned about your diet or caring for someone whose diet may be poor, ask your GP or healthcare team for a referral to a dietitian
  • stopping smoking – smoking makes you more likely to get pressure ulcers because of the damage caused to blood circulation

If you’re in a hospital or care home, your healthcare team should be aware of the risk of developing pressure ulcers. They should carry out a risk assessment, monitor your skin and use preventative measures, such as regular repositioning.

If you’re recovering from illness or surgery at home, or you’re caring for someone confined to bed or a wheelchair, ask your GP for an assessment of the risk of developing pressure ulcers.

Page last reviewed: 15 April 2020
Next review due: 15 April 2023

Pressure ulcers – Illnesses & conditions

Treatment for pressure ulcers can vary, depending on the grade of the ulcer. Treatment options may include regularly changing your position, or using special mattresses and dressings to relieve pressure or protect the skin. In some cases, surgery may be needed.

Your care team

Pressure ulcers are a complex health problem arising from many interrelated factors. Therefore, your care may be provided by a team comprising different types of healthcare professionals. This type of team is sometimes known as a multidisciplinary team (MDT).

Your MDT may include:

  • a tissue viability nurse (a nurse who specialises in wound care and prevention)
  • a social worker
  • a physiotherpist
  • an occupational therapist
  • a dietitian
  • medical and surgical experts with experience in pressure ulcer management

Changing position

It’s important to avoid putting pressure on areas that are vulnerable to pressure ulcers or where pressure ulcers have already formed. Moving and regularly changing your position helps to prevent pressure ulcers developing and relieves the pressure on the ulcers that have developed.

After your risk assessment is completed, your care team will draw up a “repositioning timetable”, which states how often you need to be moved. For some people, this may be as often as once every 15 minutes. Others may need to be moved only once every 2 hours.

The risk assessment will also consider the most effective way of avoiding putting any vulnerable areas of skin under pressure whenever possible.

You may also be given training and advice about:

  • correct sitting and lying positions
  • how you can adjust your sitting and lying position
  • how often you need to move or be moved
  • how best to support your feet
  • how to maintain good posture
  • the special equipment you should use and how to use it

Mattresses and cushions

There are a range of special mattresses and cushions that can relieve pressure on vulnerable parts of the body. Your care team will discuss the types of mattresses and cushions most suitable for you.

Those thought to be at risk of developing pressure ulcers, or who have pre-existing grade 1 or 2 pressure ulcers, usually benefit from a specially designed foam mattress, which relieves the pressure on their body.

People with a grade 3 or 4 pressure ulcer will require a more sophisticated mattress or bed system. For example, there are mattresses that can be connected to a constant flow of air, which is automatically regulated to reduce pressure as and when required.


Specially designed dressings and bandages can be used to protect pressure ulcers and speed up the healing process. Examples of these types of dressings include:

  • hydrocolloid dressings – these contain a special gel that encourages the growth of new skin cells in the ulcer, while keeping the surrounding healthy area of skin dry 
  • alginate dressings – these are made from seaweed and contain sodium and calcium, which are known to speed up the healing process

Creams and ointments

Topical preparations, such as creams and ointments, can be used to help speed up the healing process and prevent further tissue damage.


If you have a pressure ulcer, you will not routinely be prescribed antibiotics. These are usually only prescribed to treat an infected pressure ulcer and prevent the infection from spreading.

Antiseptic cream may also be applied directly to pressure ulcers to clear out any bacteria that may be present.


Certain dietary supplements, such as protein, zinc and vitamin C, have been shown to accelerate wound healing.

If your diet lacks these vitamins and minerals, your skin may be more vulnerable to developing pressure ulcers. As a result of this, you may be referred to a dietitian so that a suitable dietary plan can be drawn up for you.


In some cases, it may be necessary to remove dead tissue from the ulcer to help stimulate the healing process. This procedure is known as debridement.

If there is a small amount of dead tissue, it may be possible to remove it using specially designed dressings and paste. Larger amounts of dead tissue may be removed using mechanical means. Some mechanical debridement techniques include:

  • cleansing and pressure irrigation – where dead tissue is removed using high-pressure water jets
  • ultrasound – dead tissue is removed using low-frequency energy waves
  • laser – dead tissue is removed using focused beams of light
  • surgical debridement – dead tissue is removed using surgical instruments, such as scalpels and forceps

A local anaesthetic will be used to numb the area of skin and tissue around the ulcer so that debridement does not cause any pain or discomfort.

Maggot therapy

Maggot therapy, also known as larvae therapy, is an alternative method of debridement. Maggots are ideal for debridement because they feed on dead and infected tissue without touching healthy tissue. They also help to fight infection by releasing substances that kill bacteria and stimulate the healing process.

During maggot therapy, the maggots are mixed into a wound dressing and the area is covered with gauze. After a few days, the dressing is taken off and the maggots are removed.

Many people may find the idea of maggot therapy off-putting, but research has found that it is often more effective than more traditional methods of debridement. 


It’s not always possible for a grade 3 or 4 pressure ulcer to heal. In such cases, surgery will be required to seal the wound and prevent any further tissue damage occurring.

Surgical treatment involves cleaning the wound and closing it by bringing together the edges of the wound (direct closure), or by using tissue moved from a nearby part of the body (flap reconstruction).

Pressure ulcer surgery can be challenging, especially because most people who have the procedure are already in a poor state of health. There is a risk of a large number of possible complications occurring after surgery, including:

  • infection
  • tissue death of the implanted flap
  • muscle weakness
  • blisters (small pockets of fluid that develop inside the skin)
  • recurrence of the pressure ulcers
  • blood poisoning
  • infection of the bone (osteomyelitis)
  • internal bleeding
  • abscesses (painful collections of pus that develop inside the body)
  • deep vein thrombosis (a blood clot that develops inside the veins of the leg)

Despite the risks, surgery is often a necessity to prevent life-threatening complications, such as blood poisoning and gangrene (the decay or death of living tissue).

3. What are the best practices in pressure ulcer prevention that we want to use?

Once you have determined that you are ready for change, the Implementation Team and Unit-Based Teams should demonstrate a clear understanding of where they are headed in terms of implementing best practices. People involved in the quality improvement effort need to agree on what it is that they are trying to do. Consensus should be reached on the following questions:

In addressing these questions, this section provides a concise review of the practice, emphasizes why it is important, discusses challenges in implementation, and provides helpful hints for improving practice. Further information regarding the organization of care needed to implement these best practices is provided in Chapter 4 and additional clinical details are in Tools and Resources.

In describing best practices for pressure ulcer prevention, it is necessary to recognize at the outset that implementing these best practices at the bedside is an extremely complex task. Some of the factors that make pressure ulcer prevention so difficult include:

  • It is multidisciplinary: Nurses, physicians, dieticians, physical therapists, and patients and families are among those who need to be invested.
  • It is multidimensional: Many different discrete areas must be mastered.
  • It needs to be customized: Each patient is different, so care must address their unique needs.
  • It is also highly routinized: The same tasks need to be performed over and over, often many times in a single day without failure.
  • It is not perceived to be glamorous: The skin as an organ, and patient need for assessment and care, does not enjoy the high status and importance of other clinical areas.

3.1 What bundle of best practices do we use?

Given the complexity of pressure ulcer prevention, with many different items that need to be completed, thinking about how to implement best practices may be daunting. One approach that has been successfully used is thinking about a care bundle. A care bundle incorporates those best practices that if done in combination are likely to lead to better outcomes. It is a way of taking best practices and tying them together in a systematic way. These specific care practices are among the ones considered most important in achieving the desired outcomes.

The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers:

  • Comprehensive skin assessment.
  • Standardized pressure ulcer risk assessment.
  • Care planning and implementation to address areas of risk.

Because these aspects of care are so important, we describe them in more detail in the subsequent subsections along with helpful clinical hints. While these three components of a bundle are extremely important, your bundle may stress other aspects of care. It should build on existing practices and may need to be tailored to your specific setting. Whatever bundle of recommended practices you select, you will need to take additional steps. We describe strategies to ensure their successful implementation as described in Chapter 4.

The challenge to improving care is how to get these key practices completed on a regular basis.


The bundle concept was developed by the Institute for Healthcare Improvement (IHI). Their Web site includes a more detailed description of what is a bundle: http://www.ihi.org/ihi/topics/criticalcare/intensivecare/improvementstories/whatisabundle.htm.

Additional Information

The following article describes successful efforts to improve pressure ulcer prevention that relied on the use of the components in the IHI bundle: Walsh NS, Blanck AW, Barrett KL. Pressure ulcer prevention in the acute care setting. J Wound Ostomy Continence Nurs 2009;36(4):385-8.

3.1.1 How are the different components of the bundle related?

Each component of the bundle is critical and to ensure improved care, each must be consistently well performed. To successfully implement the bundle, it is important to understand how the different components are related. A useful way to do this is by creating or following a clinical pathway. A clinical pathway is a structured multidisciplinary plan of care designed to support the implementation of clinical guidelines. It provides a guide for each step in the management of a patient and it reduces the possibility that busy clinicians will forget or overlook some important component of evidence-based preventive care.

Some of the advantages of these clinical pathways are to:

  • Reduce variation and standardize care.
  • Provide efficient, evidence-based care.
  • Improve outcomes.
  • Educate staff as to best practices.
  • Improve care planning.
  • Facilitate discussion among staff.
  • An example of a clinical pathway detailing the different components of the bundle is found in Tools and Resources (Tool 3A, Pressure Ulcer Prevention Pathway). This color-coded tool can be used by the hospital unit team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units. This tool can be modified, or a new one created, to meet the needs of your particular setting.
  • If you prepared a process map describing your current practices (described in section 2), you can compare that to desired practices outlined on the clinical pathway.
Practice Insights

Given the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed. 

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3.2 How should a comprehensive skin assessment be conducted?

The first step in our clinical pathway is the performance of a comprehensive skin assessment. Prevention should start with this seemingly easy task. However, as with most aspects of pressure ulcer prevention, the consistent correct performance of this task may prove quite difficult.

3.2.1 What is a comprehensive skin assessment?

Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking and touching the skin from head to toe, with a particular emphasis over bony prominences.

As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. These include:

  • Identify any pressure ulcers that may be present.
  • Assist in risk stratification; any patient with an existing pressure ulcer is at risk for additional ulcers.
  • Determine whether there are other lesions and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage (MASD).
  • Identify other important skin conditions.
  • Provide the data necessary for calculating pressure ulcer incidence and prevalence.
Additional Information

It is important to differentiate MASD from pressure ulcers. The following articles provide useful insights on how to do this:

  • DeFloor T, Schoonhoven L, Fletcher J, et al. Statement of the European Pressure Ulcer Advisory Panel: pressure ulcer classification. J Wound Ostomy Continence Nurs 2005;32:302-6.
  • Gray M, Bliss DZ, Doughty DB. Incontinence associated dermatitis a consensus. J Wound Ostomy Continence Nurs 2007;34(1):45-54.
3.2.2 How is a comprehensive skin assessment performed?

A comprehensive skin assessment has a number of discrete elements. Inspection and palpation, though, are key. To begin the process, the clinician needs to explain to the patient and family that they will be looking at their entire skin and to provide a private place to examine the patient’s skin. Make sure that the clinicians’ hands have been washed, both before and after the examination. Use gloves to help prevent the spread of resistant organisms.

Recognize that there is no consensus about the minimum for a comprehensive skin assessment. Usual practice includes assessing the following five parameters:

  • Temperature.
  • Color.
  • Moisture level.
  • Turgor.
  • Skin integrity (skin intact or presence of open areas, rashes, etc.).

Detailed instructions for assessing each of these areas are found in Tools and Resources (Tool 3B, Elements of a Comprehensive Skin Assessment).

Practice Insights
  • Take advantage of every patient encounter to evaluate part of the skin.
  • Always remind staff performing comprehensive skin assessments of the following helpful hints:
    • Don’t forget to wash your hands before doing the skin assessment and after and to use gloves.
    • Make sure the patient is comfortable. Minimize exposure of body parts while you are doing the skin assessment.
    • Ask for assistance if needed to turn the patient in order to examine the patient’s backside, with a particular focus on the sacrum.
    • Look at the skin underneath any devices such as oxygen tubing, indwelling urinary catheter, etc. Make sure to remove compression stockings to check the skin underneath them.
3.2.3 How frequently should comprehensive skin assessments be performed?

Comprehensive skin assessment is not a one-time event limited to admission. It needs to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In most hospital settings, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge. In some settings, though, it may be done as frequently as every shift. The admission assessment is particularly important on arrival to the emergency room, operating room, and recovery room. It may be appropriate to have more frequent assessments on units where pressure ulcers may develop rapidly, such as in a critical care unit; or less frequently on units in which patients are more mobile, such as psychiatry. Staff on each unit should know the frequency with which comprehensive skin assessments should be performed.

Optimally, the daily comprehensive skin assessment will be performed in a standardized manner by a single individual at a dedicated time. Alternatively, it may be possible to integrate comprehensive skin assessment into routine care. Nursing assistants can be taught to check the skin any time they are cleaning, bathing, or turning the patient. Different people may be assigned different areas of the skin to inspect during routine care. Someone then needs to be responsible for collecting information from these different people about the skin assessment. The risk with this alternative approach is that a systematic exam may not be performed; everybody assumes someone else is doing the skin assessment. Decide what approach works best on your units.

Action Steps

Assess whether your staff know the frequency with which comprehensive skin assessment should be performed.

3.2.4 How should results of the comprehensive skin exam be reported and documented?

In order to be most useful, the result of the comprehensive skin assessment must be documented in the patient’s medical record and communicated among staff. Everyone must know that if any changes from normal skin characteristics are found, they should be reported. Nursing assistants need to be empowered and feel comfortable reporting any suspicious areas on the skin. Positive reinforcement will help when nursing assistants do find and report new abnormalities.

In addition to the medical record, consider keeping a separate unit log that summarizes the results of all comprehensive skin assessments. This sheet would list all patients present on the unit, whether they have a pressure ulcer, the number of pressure ulcers present, and the highest stage of the deepest ulcer. By regularly reviewing this sheet, you can easily determine whether each patient has had a comprehensive skin assessment. This log will also be critical in assessing your incidence and prevalence rates (go to section 5.1). Nursing managers should regularly review the unit log.

Action Steps

Assess the following:

  • Are results of the comprehensive skin assessment easily located for all patients?
  • Are staff comfortable reporting any observed skin abnormalities to physicians and nurse managers?

A sample sheet can be found in Tools and Resources (Tool 5A, Unit Log).

Practice Insights
  • Have a standardized place to record in the medical record the results of the skin assessment. A checklist or standardized computer screens with drop-down prompts with key descriptors of the five components of a minimal skin assessment can help capture the essential information obtained through the patient examination.
  • Communication among licensed and unlicensed members of the health care team is important in identifying and caring for any skin abnormalities. Some places have found it effective to use a diagram of a body outline that an unlicensed heath care worker can mark with any skin changes they might see while bathing or performing care activities.
3.2.5 What are some barriers to practice?

There are many challenges to the performance of comprehensive skin assessments. Be especially concerned about the following issues:

  • Finding the time for an adequate skin assessment: As much as possible, integrate the comprehensive skin examination into the normal workflow. But remember that this is a separate process that requires a specific focus by staff if it is to be done correctly.
  • Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and over bony prominences. In particular, do not confuse moisture-associated skin changes with pressure ulceration. If unsure about the etiology of a lesion, ask someone else who may be more knowledgeable.
  • Using documentation forms that are not consistent with components of skin assessments: Develop forms that will facilitate the recording of skin assessments.
  • Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing assistants, nurses, and managers is critical to success. If communication problems exist, staff development activities targeting cross-level communication skills may be in order. Nurses and managers may need to solicit and positively reinforce such reporting if nursing assistants do not have confidence in this area. Develop methods to facilitate communication. One example would be a sticky note pad that includes a body outline, patient name, and date. Aides would mark down any suspicious lesions and give the note to nurses.

An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources (Tool 3C, Pressure Ulcer Identification Notepad).

3.2.6 How can practice be improved?

Comprehensive skin assessment requires considerable skill and ongoing efforts are needed to enhance skin assessment skills. Take advantage of available resources to improve skills of all staff. Encourage staff to:

  • Ask a colleague to confirm their skin assessments. Having a colleague evaluate the skin assessment will provide feedback as to how they are doing and will help correct documentation errors.
  • Perform skin assessments with an expert. Consider having an expert or nurse from another unit round with unit staff quarterly to confirm findings from the comprehensive skin assessment.
  • Ask for clarification when they are unsure of a lesion. Take advantage of the local wound care team or other staff who may be more knowledgeable.
  • Use available resources to practice their ability to differentiate the etiology of skin and wound problems.

This slide show illustrates how to perform a skin assessment: www.authorstream.com/Presentation/ann5844-150720-skin-assessment-nursing-1-curdeline-product-training-manuals-ppt-powerpoint/

Consult the European Pressure Ulcer Advisory Panel Web site (http://www.epuap.org) for useful advice on evaluating erythema and the proper staging of pressure ulcers. 

Practice Insights

A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period.

  • When applying oxygen, check the ears for pressure areas from the tubing.
  • If the patient is on bed rest, look at the back of the head during repositioning.
  • When auscultating lung sounds or turning the patient, inspect the shoulders, back, and sacral/coccyx region.
  • When checking bowel sounds, look into skin folds.
  • When positioning pillows under calves, check the heels and feet (using a hand-held mirror makes this easier).
  • When checking IV sites, check the arms and elbows.
  • Examine the skin under equipment with routine removal (e.g., TENS units, restraints, splints, oxygen tubing, endotracheal tubes).
  • Each time you lift a patient or provide care, look at the exposed skin, especially on bony prominences.
  • Pay special attention to areas where the patient lacks sensation to feel pain or has had a breakdown in the past and if epidural/spinal pain medications are being administered. 

Return to Contents

3.3 How should a standardized pressure ulcer risk assessment be conducted?

As discussed above, one purpose of comprehensive skin assessment is to identify visible changes in the skin that indicate increased risk for pressure ulcer development. However, factors other than skin changes must be assessed to identify patients at risk for pressure ulcers. This can best be accomplished through a standardized pressure ulcer risk assessment.


3.1 What is a standardized pressure ulcer risk assessment?

After a comprehensive skin examination, pressure ulcer risk assessment is the next step in pressure ulcer prevention. Pressure ulcer risk assessment is a standardized and ongoing process with the goal of identifying patients at risk for the development of a pressure ulcer so that plans for targeted preventive care to address the identified risk can be implemented. This process is multifaceted and includes many components, one of which is a validated risk assessment tool or scale.

Other risk factors not quantified in the assessment tools must be considered. Risk assessment does not identify who will develop a pressure ulcer. Instead, it determines which patients are more likely to develop a pressure ulcer, particularly if no special preventive interventions are introduced. In addition, risk assessment may be used to identify different levels of risk. More intensive interventions may be directed to patients at greater risk.

Action Steps

Ask yourself and your team:

  • Do you have a policy about who is responsible for the risk assessment on admission and thereafter?
  • Does everyone know the process for performing risk assessment?
3.3.2 Why is a pressure ulcer risk assessment necessary?

Pressure ulcer risk assessment is essential for a number of reasons:

  • It aids in clinical decisionmaking. Many clinicians are not skilled in identifying patients at risk for developing pressure ulcers. Use of a standardized risk assessment helps to direct the process by which clinicians identify those at risk and quantify the level of this risk.
  • It allows the selective targeting of preventive interventions. Pressure ulcer prevention is resource intensive. Resources should be targeted toward those at greatest risk who would most-benefit.
  • It facilitates care planning. Care plans focus on the specific dimensions that place the patient at greatest risk.
  • It facilitates communication between health care workers and care settings. Workers have a common language by which they describe risk.
Action Steps

Ask yourself and your team:

  • Do the unit staff understand why they are doing the risk assessment?
  • Are unit staff communicating the risk assessment results to all clinicians who need to know?
3.3.3 How is risk assessment performed?

Pressure ulcer risk assessment is a standardized process that uses previously developed risk assessment tools or scales, as well as the assessment of other risk factors that are not captured in these scales. Risk assessment tools are instruments that have been developed and validated to identify people at risk for pressure ulcers. Typically, risk assessment tools evaluate several different dimensions of risk, including mobility, nutrition, and moisture, and assigns points depending on the extent of any impairment.

Clinicians often believe that completing the risk assessment tool is all they need to do. Help staff understand that risk assessment tools are only one small piece of the risk assessment process. The risk assessment tools are not meant to replace clinical assessments and judgment but are to be used in conjunction with clinical assessments.

Many other factors might be considered as part of clinical judgment. However, many of these factors, such as having had a stroke, are captured by existing tools through the resulting immobility. Several additional specific factors should be considered as part of the risk assessment process. However, also remember that patients who are just “not doing well” always seem to be at high risk for pressure ulcers.

  • Presence of a pressure ulcer: All patients with an existing pressure ulcer should be considered at-risk for an additional ulcer.
  • Prior Stage III or IV pressure ulcers: When Stage III or IV ulcers close through a process of scar tissue formation and eventual epithelialization, the resulting skin is not normal as it lacks its former tensile strength and is very prone to break down again.
  • Hypoperfusion states: Patients who are not perfusing vital organs as a result of conditions such as sepsis, dehydration, or heart failure are also not adequately perfusing the skin. Minimal amounts of pressure may then cause ulceration.
  • Peripheral vascular disease: Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels.
  • Diabetes: Patients with diabetes have consistently been shown to be at increased risk of pressure ulcers.
  • Smoking: Smoking interferes with oxygen delivery. Smoking is associated with recurrence of pressure ulcers postsurgery and likely increases risk of new pressure ulcers.
  • Restraint use: Patients with physical restraints have limited mobility in addition to having pressure applied at the site of the restraints. Chemical restraints with resulting sedation may lead to rapid decline in mobility.
  • Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients at exceptionally high risk. The level and completeness of the spinal cord injury is critical in this determination. Also consider if the individual is receiving epidural/spinal pain medication.
  • End-of-life/palliative care: Individuals in the terminal stages of disease may have failure of multiple organ systems, including the skin.
  • Operating room (OR) and emergency room (ER) stays: Prolonged time on a hard surface or in one position increases the risk of skin breakdown. This often happens in an OR or ER, with lengthy procedures, or while transporting a patient,. Always consider the length of time that the patient may need to stay in one position. Patients who undergo a procedure longer than 4 hours are at particularly high risk.
Practice Insights

Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development.

3.3.4 What risk assessment scales are used most often?

Remember that risk assessment scales are only one part of a pressure ulcer risk assessment. These scales or tools serve as a standardized way to review some factors that may put a person at risk for developing a pressure ulcer. Research has suggested that these tools are especially helpful in identifying people at mild to moderate risk as nurses can identify people at high risk or no risk. All risk assessment scales are meant to be used in conjunction with a review of a person’s other risk factors and good clinical judgment.

While some institutions have created their own tools, two risk assessment scales are widely used in the general adult population: the Norton Scale and the Braden Scale. Both the Norton and Braden scales have established reliability and validity. When used correctly, they provide valuable data to help plan care.

The Norton Scale is made up of five subscales (physical condition, mental condition, activity, mobility, incontinence) scored from 1-4 (1 for low level of functioning and 4 for highest level of functioning). The subscales are added together for a total score that ranges from 5 to 20. A lower Norton Scale score indicates higher levels of risk for pressure ulcer development. Scores of 14 or less generally indicate at-risk status.

The Braden Scale is made up of six subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear) scored from 1 to 4 or 1 to 3 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6 to 23. A lower Braden Scale score indicates higher levels of risk for pressure ulcer development. Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines.

Other scales may be used instead of the Norton or Braden scales. What is critical is not which scale is used but just that some validated scale is used in conjunction with a consideration of other risk factors not captured by the risk assessment tool. By validated, we mean that they have been shown in research studies to identify patients at increased risk for pressure ulcer development.

Action Steps

Ask yourself and your team:

  • Are we using a risk assessment tool in conjunction with the assessment of additional specific patient risk factors?
  • When and what kind of training did the staff receive on how to use and interpret the scales?
  • Are risk assessment results being used as a basis for planning care?

Copies of the Braden and Norton scales are included in Tools and Resources (Tool 3D, Braden Scale , and Tool 3E, Norton Scale ).


Additional information on the Braden and Norton scales may be found at the following Web sites:

3.3.5 What risk assessment should be used in special populations?

The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in terms of differentiating the level of risk in special populations. These include pediatric patients, patients with spinal cord injury, palliative care patients, and patients in the OR. Risk assessment tools exist for these special settings but they may not have been as extensively validated as the Norton and Braden scales.


Consider the following resources for risk assessment in special populations:

  • Palliative Care: Hunters Hill Marie Curie Centre Risk Assessment Tool. Chaplin J, McGill M. Pressure sore prevention. Palliative Care Today 1999;8(3):38-39.
  • Home Care: Braden Scale for Predicting Pressure Sore Risk in Home Care. Available at: www.bradenscale.com.
  • Pediatrics:
    • Braden Q (21 days to 8 years). Quigley SM, Curly MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Spec Pediatr Nurs 1996;1(1):7-18.
    • Glamorgan Scale (birth to 18 years). Willock J, Harris C, Harrison J, et al. Identifying the characteristics of children with pressure ulcers. Nursing Times 2005;101(11):40-43.
    • Pediatric Waterlow (neonate to 16 years). Waterlow J. Pressure sore risk assessment in children. Pediatr Nurs 1997;9(6):21-24.
    • Neonatal Skin Risk Assessment Scale (NSARS) (26 to 46 weeks). Huffines B, Logsdon MC. The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Issues Compr Pediatr Nurs 1997;20:103-14.
3.3.6 What information do you get from using a risk assessment scale?

Overall scale scores provide data on general pressure ulcer risk and help clinicians plan care according to the amount of risk (high, moderate, low, etc). Subscale scores provide information on specific deficits such as moisture, activity, and mobility. These deficits should be specifically addressed in care plans. Remember, even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially as their condition changes.


3.7 How often is a pressure ulcer risk assessment done?

Consider performing a risk assessment in general acute care settings on admission and then daily or with a significant change in condition. However, pressure ulcer risk may change rapidly, especially in acute care settings. Therefore, recommendations for frequency of risk assessment will vary.

In settings where patients’ status may change quickly, such as in critical care, risk assessment should be performed more frequently, such as every shift. In the OR, recommendations exist to assess on admission, at discharge to the recovery room, and periodically for operations lasting longer than 4 hours. (Consider the time in the holding and recovery rooms when assessing the time). For patients with more stable conditions, such as acute rehabilitation, pressure ulcer risk assessment may be less frequent. What is important is that the frequency of pressure ulcer risk assessment be individualized to the person’s unique setting and circumstances.

Action Steps

Considering the specific patient situation, ask yourself and your team:

  • How often should the risk reassessment be done on your unit?
  • How often is it actually being done?

For more information on risk assessment in the OR, see the recommendations from the Minnesota Hospital Association Safe Skin Campaign: http://www.mnhospitals.org/inc/data/tools/SafeSkin-Toolkit/OR-pressure-ulcer-recommendations.pdf.

3.3.8 How should pressure ulcer risk assessment be documented and communicated?

Documenting pressure ulcer risk is essential to ensure that all staff are aware of patients’ pressure ulcer risk status. While documenting in the medical record is necessary, documentation alone may not be sufficient to ensure that all staff know the level of risk. Among the options to consider for complete documentation are:

  • Having a dedicated form (computerized or paper) in the medical record.
  • Incorporating results in the daily patient flowsheets.
  • Including results as part of patient report or handover.
  • Having a separate form for the pressure ulcer risk assessment tool that allows multiple date entries.
  • Putting results on patient card or daily patient care worksheet.

Remember that in documenting pressure ulcer risk, you want to incorporate not only the score and subscale scores of the standardized risk assessment tool, but also other factors placing the individual at risk. This information is often included in narrative text.

Risk status should be communicated orally at shift change or by review of the written material in the medical record or patient care worksheet. Consider innovative approaches to conveying level of risk. For example, some facilities have color-coded the patient wristband, placed stickers on the patient chart or worksheet, or used picture magnets on the doors to indicate risk status.


3.9 How can we improve the accuracy of pressure ulcer risk assessment?

The accuracy of a risk assessment scale depends on the person completing it. Experience has shown tremendous variability among staff even when evaluating the same patient. Therefore, training in how to use the scale is needed to ensure consistency.

Action Steps

It is important to check how risk assessment is being performed on each unit.

  • Look at the patient record and see if the scores have been consistent. Wide fluctuations in risk are unusual in stable patients. Similarly, when there is a major change in clinical condition, has the risk score changed?
  • Select a patient and see if the assessment is accurate. Staff may give the patient “the benefit of the doubt” and make scores better than they are.

Information may be found in the Hartford Institute for Geriatric Nursing’s Try This Series at http://www.consultgerirn. org/uploads/File/trythis/issue05.pdf.  Refer to Issue 5 under the General Assessment Series.

Lindgren M, Unosson M, Krantz AM, et al. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs 2002;38(2):190-9.

Additional Information

Learn more about risk assessment:

  • Magan MA, Maklebust J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care 2009;22(2):83-92.
  • Magan MA, Maklebust J. Multisite Web-based training in using the Braden Scale to predict pressure sore risk. Adv Skin Wound Care 2008;21(3):124-33.

What Every Caregiver Should Know About Bed Sores

Bed sores, also known as pressure ulcers, are a serious concern for family caregivers and medical professionals in long-term care settings and hospitals. According to the National Pressure Injury Advisory Panel (NPIAP), approximately 2.5 million patients develop pressure ulcers each year and 60,000 die as a direct result of these injuries. People who are bedridden or spend significant time in a bed or a chair and cannot shift positions on their own are at risk. While a small, irritated area of skin does not sound like a huge concern to the average person, this minor annoyance can quickly develop into a major health problem for frail elders.

Firstly, Louise Aronson, MD, practicing geriatrician, Professor of Medicine at the University of California, San Francisco, and author of Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life, wishes to clarify some terminology that may confuse caregivers: the terms bed sore, pressure sore, pressure ulcer and decubitus ulcer all refer to the same problem. “Pressure ulcer is the preferred term these days,” Dr. Aronson says, “because pressure is the main culprit and these wounds can certainly happen in places other than beds.”

Why Do Seniors Get Bed Sores?

Pressure ulcers are areas where the skin and/or underlying tissues have been damaged, often leading to an irritated, open wound.

“This happens when tissue is compressed between two relatively hard surfaces, such as a bed or chair and a bone inside the body,” Dr. Aronson explains. “The result is essentially the skin equivalent of a heart attack or stroke: the blood supply is cut off to that area and the deprived tissue becomes injured and dies.”

Three Causes of Bed Sores

Interrupted blood flow and damage to the skin can occur due to:

  1. Pressure from sitting or lying too long without shifting position;
  2. Friction or rubbing, which can occur during transfers, such as when the one’s body is dragged over bedsheets; and
  3. Shearing, which occurs when one’s body slides in a chair or bed so that the skin slides or pulls away from the supportive tissues below it.

Of these, Dr. Aronson says that pressure is by far the most common culprit. “Of course, it is not quite that simple, or we would all have these wounds as a result of our everyday activities, but some people are at higher risk than others,” she notes. “The skin of older adults offers much less protection from injury than younger skin.”

People who are paralyzed or have severe mobility issues may be unable to move themselves even subtly to allow increased blood flow to compressed areas. Seniors are at higher risk because skin thins, loses elasticity and becomes more fragile with age. Family caregivers caring for elders who are bedridden or wheelchair bound must be particularly careful to prevent pressure ulcers from forming.

Perspiration from a fever or moisture from incontinence issues can also make senior skin weaker and more prone to irritation. Certain lifestyle factors and chronic health conditions that affect circulation, mobility and sensory perception and can increase this risk as well. Common risk factors include cancer, stroke, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, diabetes, malnutrition, chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD), heart failure and hip fractures. However, one study revealed that smoking, urinary incontinence and bowel incontinence were a few of the most considerable factors in the development of pressure ulcers.

Warning Signs of Skin Breakdown in Elderly Loved Ones

Dr. Aronson stresses that it is always better to prevent a serious medical problem than to deal with it after it has already caused significant damage. If areas of skin irritation are detected early on, proper intervention and skin care can stop or delay the development of painful open wounds. This is incredibly important since these sores can become very deep and even infected.

The first signs of pressure sores appear when the skin is still intact. Both family and professional caregivers should regularly inspect care recipients for the following signs of skin breakdown.

Changes in Skin Color

Keep an eye out for signs of skin irritation. These marks may be blue or purple in individuals with darker skin and pink or red in those with lighter skin.

Unusual Fluctuations in Skin Temperature

Excess warmth indicates inflammation, while coolness indicates little or no blood flow to the area. Both of these are bad signs.

Changes in Tissue Consistency

Affected areas may feel exceptionally soft or boggy and different from healthy surrounding tissue.

Unusual Sensations

Numbness, burning, itching, pain or tingling often occurs in at-risk areas when a wound is developing.

Blisters or Abrasions

These typically minor wounds often signify an existing superficial injury that can easily worsen.


“Deep bruises over at-risk areas, which are actually more serious, often indicate significant damage below the skin,” warns Dr. Aronson. “This is common after a frail senior falls. It may look like a simple, nasty bruise, but it should be carefully monitored in case it turns into a sore.”

Common Sites of Bed Sores

Different body positions are associated with certain vulnerable spots where bed sores usually develop. For example, sitting is most likely to cause sores on a senior’s bottom and back. Another high-risk position is lying down, which can cause sores in any of the following places:

  • Sacrum (the large bone at the base of the spine just above the tailbone)
  • Coccyx (tailbone)
  • Heels of the feet
  • Sides of the hips (more specifically, parts of the femur called trochanters and the iliac crests of the pelvis)
  • Pelvic “sit bones” where weight is placed when sitting (called the ischial tuberosity)
  • The back along places where the vertebrae protrude
  • Any areas of the head that are in contact with the bed surface, a pillow, etc.

“Other places include the ears, insides of the knees, ankles, shoulder bones, elbows, and anywhere else that may be pressed against a hard surface for extended periods of time,” emphasizes Dr. Aronson. “This may be caused by something as simple as a leg against a bedrail or a chin resting against a collarbone.”

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How to Prevent Bed Sores in Elderly Loved Ones

There are special products, positioning techniques and accessories that can help prevent skin breakdown, but the most important factor is closely monitoring a loved one’s skin condition on a regular basis to know when these tools are needed.

Dr. Aronson recommends the following measures to prevent bed sores:

  1. Reposition at least every two hours. Following a strict repositioning schedule is crucial when caring for seniors with limited mobility. Depending on a patient’s abilities, this may include alternating from standing to sitting and/or moving from one side of the body to the back and then to the other side when lying down.
  2. Protect at-risk areas with extra cushioning. For example, putting pillows between the legs in bed, using special mattress overlays, or padding a chair/wheelchair with cushions that are proven to decrease pressure over time can be very useful. These can be made of foam or gel or contain water or air. Regular cushions and foams help but only very briefly. Research pressure sore prevention products carefully before making a purchase because some can actually cause more harm.
    Browse recommended senior care products for the bedroom here »
  3. Perform regular (at least daily) skin checks of at-risk areas.
  4. Keep skin lubricated and free of excess moisture. Gently applying the right lotions and creams can make the skin more resilient. Barrier creams should be used regularly after every adult brief change to promote skin integrity. Even though moisture is detrimental, note that overly dry, cracked areas of skin can pose problems as well. Use mild soaps and warm water when bathing or cleaning soiled areas to prevent inflammation and infection. To avoid skin tears and other injuries, avoid scrubbing and rubbing motions when helping a senior bathe, dry off and moisturize.
    Browse recommended incontinence care products here »
  5. Provide nutritious meals that include protein, vitamins and minerals. There is no one best diet for preventing bed sores, but inadequate nutrition can slow or stop healing and regenerative processes. Caloric intake is also important for preventing significant weight loss. Thin people tend to have less body fat, muscle mass and other tissue to help cushion commonly affected bony areas. On the other hand, excess weight can put added stress on the body’s pressure points. Maintaining a healthy weight is an important part of preventing skin breakdown.

How to Treat Bed Sores

If a loved one develops one of these wounds, it is important to understand the severity of the injury to devise an appropriate course of treatment. Pressure ulcers are classified into four general stages according to their appearance.

Bed Sore Staging and Treatment

  • Stage 1 Bed Sore: Intact skin presents with changes in color, temperature, consistency or sensation. Administer immediate pressure relief and gentle cleansing and conditioning of the skin with mild soap and moisturizing lotion. A barrier cream may be applied to compromised skin to help protect against excess moisture, bacteria and fungal infections.
  • Stage 2 Bed Sore: Characterized by a shallow ulcer with only pink tissue in it or a blister filled with clear fluid or blood. Stage 2 pressure ulcers should be cleaned with a saltwater (saline) rinse or a cleanser recommended by a health care provider. Special gels and creams are applied to the shallow ulcer once or twice daily and then covered with gauze. Blisters are closely observed and sometimes covered with a thin, transparent film for added protection.
  • Stage 3 Bed Sore: Consists of a deeper ulcer, which may extend down to subcutaneous fat and have yellow “slough” tissue or a thin scab. Deeper ulcers often require multiple treatments. The ulcer base must be kept moist, and this can be done with the same creams used for stage 2 wounds if the ulcer bed is clean. These sometimes require other treatments, including cutting away the dead tissue or applying creams that help it dissolve. If there is a defect because the wound is deep, the ulcer must be packed. Many forms of insurance cover durable medical equipment (DME) like pressure-reducing support surfaces and other devices if they are prescribed by a physician for the treatment and prevention of pressure ulcers. Medicare Part B covers medically necessary DME rentals and purchases.
  • Stage 4 Bed Sore: A deep ulcer that extends down to bone, tendon or muscle. Wounds at this stage often extend under the surrounding intact skin or tunnel into deeper tissues. Eschar (dead tissue), slough, scab or some combination of these may also be present. These wounds often require cleaning out of dead tissue with a scalpel or scissors through a process called debridement. This can be done by a professional in the home or at a clinic, but more extensive damage that is very deep near the intestines or other critical organs may require surgical attention. After debridement, the treatment is like that of a stage 3 wound. Injuries of this stage always require careful, regular monitoring and treatment by experts.
  • Unstageable Bed Sore: This category describes wounds in which eschar (usually yellow, tan, green, gray or brown in color) or a scab (black or brown) covers the base, so it is unclear if it is Stage 3 or 4. Ideally, these are treated by removing dead tissues, staging the wound and then treating it accordingly.
  • Deep Tissue Injury: These often develop in high-risk areas and present as purple or maroon skin discolorations with changes in temperature, consistency and/or sensation. These signs indicate serious injury below the intact skin. These unique wounds can develop into high stage ulcers very quickly, even with optimal treatment. They require monitoring at least daily in case the deep wound opens to the surface or becomes infected. Pressure relief is essential.

“There are many treatments for each stage, so this list merely highlights common options,” advises Dr. Aronson. “For all but the most superficial wounds that respond to efforts to decrease pressure or friction, it is very important to seek care from a doctor, nurse practitioner (NP), physician assistant (PA) or wound care nurse with specialized expertise in these injuries.”

Regardless of the stage of the wound, decreasing pressure to the affected area is necessary to prevent worsening and begin healing. If pain persists once pressure has been taken off the affected area, Dr. Aronson urges family caregivers to seek medical care immediately for their loved ones. This may be a sign of a serious infection or other complication.

Complications of Pressure Ulcers

The most common complication is a worsening wound or development of more wounds due to delayed or improper care. Dr. Aronson warns that wounds can become infected and even lead to life-threatening systemic infections, like sepsis or infections in the underlying bones (osteomyelitis) that must be treated with weeks to months of intravenous antibiotics.

“More severe wounds can permanently damage muscles and nerves or leave defects in the body,” says Dr. Aronson. “Sites of past wounds are also at higher risk for new pressure ulcers to develop.”

For people who are very old or terminally ill from cancer, heart disease, advanced dementia or other serious conditions, pressure ulcers can be a sign of the body shutting down as death approaches. “For family members, the appearance of a bed sore is a very important reason for discussing a loved one’s priorities for end-of-life care and enlisting help from a specialist in geriatrics or palliative care,” Dr. Aronson advises. “This is often an appropriate time to consider hospice care since their nurses and other staff can help manage the wounds in the context of the patient’s priorities and comfort.”

Read: Why Family Members Wait Too Long to Call Hospice

The take-home message is that pressure ulcers are preventable and treatable. However, they can appear and worsen very quickly, so repositioning, consistent skin care and close inspections are crucial. It may be uncomfortable for you and your loved one to look for signs of skin breakdown, but it is a necessary component of quality senior care.


It is not difficult to avoid bedsores in most cases, it is enough to regularly carry out prophylaxis. A medical assessment of the risks of this wound should be carried out and specific measures to reduce the risk (for example: pressure relief, preventive skin care) by minimizing risk factors should be established.

Once a pressure ulcer has developed, a coordinated treatment plan needs to be developed to heal and remediate the pressure ulcer.It is necessary to provide suitable conditions for the early healing of wounds. These include a clean wound, functioning blood circulation, a balanced diet in terms of both calories and nutrients, and adequate fluid intake. The latter condition is often a problem for the elderly (as a rule, the daily fluid intake should be 40 ml per kg of body weight).

Depending on the condition of the wound, pressure sores are divided into four stages

Stage 1
The skin is intact but has redness that does not turn white when touched.

Stage 2
The tissues of the epidermis or dermis are damaged, possibly damage to both layers of the skin. The damage manifests itself clinically as a wound or blister. The surrounding skin may be reddened.

Stage 3
All superficial layers of the skin, fatty tissues, up to muscles are damaged. The bedsore looks like a deep funnel.

Stage 4
All soft tissue, bone or articular structures are destroyed.

Anyone can develop a pressure sore, but elderly, bedridden, paralyzed and malnourished patients are at higher risk.

Identifying people at risk for pressure ulcers and taking preventive measures are vital steps to reduce the incidence of pressure ulcers. Individual risk of developing pressure ulcers can be determined using risk assessment tools such as the Braden scale.

Braden Scale is a rating scale consisting of 6 parameters.

  • Sensory perception (ability to respond meaningfully to discomfort)
  • Humidity (moisture level of the skin)
  • Activity (degree of physical activity)
  • Mobility (the ability to change and control body position)
  • Power Problems
  • Rubs

The most important aspect of the prevention and treatment of pressure ulcers is pressure reduction.This can be achieved through frequent changes in patient position, use of anti-decubitus mattresses, or special equipment to reduce stress. Proper treatment should include thorough cleaning and treatment of wounds, removal of the abdominal membrane from the wound, and the release of the wound environment from urine and feces. Stages 3 and 4 often require surgery.

Prevention of pressure sores – Ravijuhend

This patient guide is based on the Estonian guideline “Care for pressure ulcers – their prevention and treatment”, approved in 2015, and the topics presented there along with recommendations.In this manual, you will find the recommendations that are most important from the patient’s point of view. The guide is intended for those groups of patients who are at increased risk of pressure ulcers, as well as for their loved ones and healthcare professionals.

The Patient Guide provides an overview of pressure ulcers as a phenomenon, their causes and locations, and how they can be prevented. The compilers of the guide are experts in the field, dealing with the prevention and treatment of pressure ulcers every day.Consideration was given to the importance of the topic, the readability of the text, figures and tables to the reader in the preparation of the manual, and these requirements were validated by patients with experience with pressure ulcers and by nursing staff.

The purpose of this guide is to help prevent pressure ulcers for patients at home and to help organize treatment if pressure ulcers have already formed. The Patient Guide contains basic general guidelines, but since the condition of each patient is very individual, this must be taken into account when reading this guide.

In the appendices of the manual, you will find advice on the most suitable posture methods for supporting the body, examples of medical aids and possible benefits from the Health Insurance Fund, contacts of relevant organizations and advice on healthy eating habits.

  • Every day to check the condition of the skin
  • Learn to identify the primary signs of pressure ulcers – redness of the skin, which does not disappear after release from pressure.
  • Change your position as often as possible, at least after every 2-4 hours.
  • When changing the position of the body of a person with limited motor activity, several people should help him to avoid rubbing the patient’s skin on the sheets.
  • When changing position, use special aids (eg slippery sheet, trapeze).
  • To maintain the selected position of the body and to avoid slipping, the patient must be supported with pillows or other aids.
  • In case of urinary and fecal incontinence, the skin should be wiped clean with a suitable pH (5.5) cleaning agent.
  • In case of excessive moisture or, conversely, excessive dryness of the skin, choose appropriate protective creams and emulsions.
  • Patients with limited physical activity should be offered a balanced diet and beverages to avoid malnutrition.
  • In the event of pressure sores or complications, you should immediately contact your family nurse or family nurse.

If the patient has limited physical activity, then other health problems, including bedsores, may occur. Pressure sores can often be painful and may take several months to take care of. All this affects the quality of life of the bedridden patient, slows down the recovery from the underlying disease and is a serious burden both for himself and for the nursing staff. With consistent, proper care, it is possible to prevent pressure sores from occurring.

A pressure sore is a localized injury to the skin and / or subcutaneous tissue, which usually occurs in the areas of the body closest to the skin, under the influence of pressure or with the combined effects of sliding, friction and pressure .

Pressure ulcers can occur in all patients, but some patients are more susceptible to their occurrence than others. Pressure ulcers form more often under the influence of the following factors:

  1. Limited traffic. The risk is increased if the patient has to lie in bed all the time.The condition can worsen if the patient himself cannot move the body or limbs without assistance, as well as when he cannot hold the body in the position in which he was laid, and slides into bed in an incorrect position. This creates constant friction between the skin and the sheets, which increases the risk of pressure sores. Patients who are forced to be in a wheelchair all day are also at high risk of pressure ulcers.
  2. Sensory disorders. The risk is increased in such cases when the patient himself does not feel any discomfort or pain, usually accompanying long-term lying in one position, or does not respond to such signs in a timely manner. If a person has constant drowsiness or other disturbances of consciousness, then such circumstances can be called very dangerous, since in this case the reaction to unpleasant sensations will be even more delayed (for example, under the influence of sedatives).
  3. Skin moisture level. The risk increases even more if the person sweats a lot (clothes or sheets are constantly wet) or if they have urinary or fecal incontinence and diapers are used every day.
  4. Food. The risk of pressure ulcers is increased if the patient is on an inadequate diet and therefore suffers from weight loss. For example, if the patient eats at best a third of the portion of food and drinks very little liquid.

(The list is sourced from the Braden Risk Scale 3 , which assesses the risk of pressure ulcers in healthcare settings).

In addition to the above, the general condition of the body and concomitant diseases play an important role here. Conditions and diseases that can contribute to the occurrence of pressure ulcers:

  • Old age
  • Disorders of the ability to express desires / feelings
  • Post-traumatic period (fracture of the tibia, long-term wearing of a cast or other injuries requiring fixation)
  • Spinal injury or other sensory disorders
  • Overweight or, conversely, underweight.Any other damage to the skin (for example, people who have had bedsores before).
  • Diabetes and cardiovascular disease ( 4 , 5 , 6 )

Watch videos (in Estonian)

Lamatiste mõiste ja tekkepõhjused, Bradeni skaala kasutamine

Bedsores are most likely to occur in areas of the body that are constantly under pressure. First of all, bedsores can occur in the following parts of the body: the back of the head, the area behind the ears, elbows, shoulder blades, the entire area of ​​the buttocks, thighs, knees, ankles and heels.These are the places where the surface of the bone is very close to the skin.

Figure 1. Areas of high risk of pressure ulcers

First signs of bedsores

  • Redness of the skin in areas of the body at risk that do not disappear with release from pressure.
  • Compared to intact areas, the reddened area may be more painful, thickened, warmer, or colder.

Figure 1. Pressure ulcers on the back

Figure 2.Pressure ulcers in the pelvic area

Figure 3. Bedsores in the area of ​​the buttocks and lower back

Further development of pressure ulcers

  • Changes cover the entire skin tissue
  • The skin bursts and a superficial ulcer or blister occurs.

Figure 4. Bedsores in the area of ​​the buttocks and lower back

Further complications of pressure ulcers

  • The bedsore begins to cover the underlying adipose tissue and muscles and in the final stage reaches the bone, forming fistulas and abscesses.
  • Pressure ulcers develop very quickly without timely intervention.
  • The tissue damage associated with pressure ulcers may actually be much larger and more voluminous than is initially seen on the surface of the skin.

Figure 5. Bedsores in the buttocks and lower back

Since bedridden patients often have nerve damage, they may not complain of pain. Because of this, damage often goes unnoticed. When the first signs of pressure ulcers appear, you need to immediately pay attention to them in order to avoid deterioration of the condition.

The rate of development of pressure ulcers depends on the general condition of the patient and the methods of care, and therefore is very individual. From the onset of reddening of the skin to deep tissue damage, it can take several hours or weeks.

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Condition / Skin Assessment

Every patient with movement disorders has known risk factors, which begin to exert their influence upon the confluence of individual adverse circumstances.If the patient has the risk factors listed in the previous chapter, then proceed as follows:

  • Examine and evaluate the skin of the bed patient (especially the high-risk area) as often as possible. Do this during your grooming routine – when you change your underwear, do your morning toilet, or change diapers.
  • Keep skin dry and clean.
  • If the patient complains of pain, burning sensation or pressure in any area, pay attention to it immediately.This may be the first symptom of a pressure sore.
  • If redness occurs on the skin that does not disappear after release from the pressure, then this can be considered the first sign of a pressure ulcer.
  • Never massage the reddened area! It has been found that massaging the injured area can lower skin temperature and lead to tissue degeneration, which in turn can trigger pressure ulcers .

Changing and supporting body position

The best way to prevent pressure ulcers is to change the position of the body, as a result of which the area of ​​the body is relieved of pressure.If the patient himself is able to change his position, then this should be done as soon as possible. The position of the body should be changed immediately if the patient feels discomfort in the area of ​​the body under pressure. If possible, the patient in bed should do gymnastics for the limbs. It speeds up blood circulation and helps prevent pressure ulcers. If the patient cannot change his position himself, then for this you need to find an assistant.

If the risk of pressure ulcers is very high and the patient lies on a regular mattress, then the time spent in one position should be further reduced.The patient should be rotated every 2 hours. The use of special mattresses to prevent pressure sores allows you to change position once every 4 hours. In this case, it is imperative to take into account the peculiarities of the skin and the wishes of the patient himself. The position must be changed at night. Suitable body positions: on the side, on the back, on the stomach and half-side. To fix in the desired position of the body, you need to make supports from the pillows. The headboard can only be raised 30 degrees during meals or other grooming procedures.When the head is raised, more pressure is placed on the buttocks, which increases the risk of pressure sores. Correct and incorrect positions can be viewed in the appendices of this manual.

If the patient cannot change his position himself, he needs help, it is better if it is more than one assistant. In this case, the patient should not move in such a way that the body does not slip on the bed linen. If the change of position is carried out by two assistants, then the risk of new damage during movement and friction is thus reduced.Try to involve the patient in the change of position in order to energize him and reduce your stress.

Aids and special equipment (including bed, mattresses)

In order to provide good care, it may be necessary to change the entire household in accordance with the needs and capabilities of the patient. Caregivers or family members should have access to the patient’s bed, preferably from both sides.To monitor the condition of the skin, the bed must be in a well-lit area. Care products should be nearby and easily accessible.

The more time the patient spends in bed, the more important the quality of the bed and mattress becomes. Ideally, the bed can be height-adjustable to make it easier for the assistant to work and to make it easier to change the position of the patient’s body. If possible, the bed should have a special mattress or mattress topper (see Appendix 2 “Aids” of this manual, Figures 1-2, p.eighteen). A special medical Australian sheepskin is also considered suitable, which will help maintain the correct humidity or temperature. In Estonia, all the aforementioned care products can be bought or rented. The purchase of some medical aids is eligible for benefits from the Health Insurance Fund (see appendix 3, page 21).

The use of aids makes the caregiver’s job easier and ensures that the patient’s skin is not damaged by inappropriate care practices or the environment.Therefore, it is advisable to use aids to change the position of the body (for example, a sliding sheet and / or table, lifting sheets). The bed should be attached to those care products that the patient can use himself (for example, a belt at the bottom of the bed, a trapezoid at the head of the bed, etc.) To prevent pressure sores in the heels, it is advisable to raise them with pillows. Ordinary pillows will work, but you can also use the specially designed supports .They should be set so that the heel area is in the so-called floating position. For the prevention of pressure ulcers, it is not recommended to use rings made of various materials, as they can exert excessive pressure in the area of ​​contact with it. To find the right aids, be sure to contact your Family Nurse and Physician, Home Care Nurse or the supplier of the aids! (see Appendix 3 on page 21).

Bed linen

Whenever possible, choose bedding and underwear made from natural materials that absorb moisture and at the same time allow air to pass through.Sheets (at the same time absorbent sheets that prevent the bed from getting wet) should be laid in the smoothest possible way. The slightest folds and unevenness can create discomfort for the patient and damage his skin.


If the patient’s skin is healthy and does not have urinary or fecal incontinence, normal skin care can be continued. The pH of the skin care product should be 5.5. After rubbing the skin, it should remain dry.Do not rub or massage the pressure sore area, it can only get wet easily.

Use protective skin creams and emulsions if the skin is too dry or too moist, if there is swelling or other signs of inflammation (redness, pain, warmth). In the case of too dry skin, creams can help prevent cracking and fragility of the skin. If the skin is too damp (urinary and fecal incontinence, excessive sweating), choose a cream that creates a waterproof protective layer and prevents irritants from damaging the skin.Change diapers as needed, without waiting for their maximum filling. If possible, the skin should be allowed to breathe a little. For urinary and fecal incontinence, prefer a product with a suitable pH (5.5).

Power supply

The risk of pressure ulcers is higher in malnourished patients, therefore special care should be taken in patients with low weight. Offer nutritional formula that is energy-efficient and fortified with minerals and vitamins.Consider the patient’s own preferences. Specialty nutrient mixtures can be found in pharmacies. No single nutrient has been scientifically proven to be effective in preventing pressure ulcers. Nutrition must be balanced! ( 10 , 11 , 12 ).

In Estonia, the Institute for Health Development is responsible for collecting and disseminating information on good nutrition.
Basic principles of a healthy and balanced diet:

  1. There is a need according to the needs.
  2. Nutrients required by the body must be consumed in the correct proportions.
  3. You can eat everything that is tasty, but in moderation
  4. Meals should be varied.

Further information can be found on the website

The Institute for Health Development has created a website to evaluate their diet and to create a personal nutrition program.

Condition Assessment

First of all, you need to get an overview of the extent of the damage.To do this, you need to free the area of ​​damage from pressure and clothing. Examine the patient’s skin in a well-lit area. Try the damaged area with your hand. If the area turns red and the redness does not disappear after release from the pressure, then most likely we are dealing with an incipient bedsore. You can do a test near the damaged area: press your finger on healthy skin – after removing the fingers, a lighter area appears on the skin, which over time will again become the same as the rest of the skin.If the blood supply is impaired in the area being examined, then such a reaction does not occur.

If the skin in the damaged area is still healthy, then it does not need to be covered with anything. If the skin is too dry or if there is a danger that the skin comes into contact with urine, then the skin only needs to be moisturized.

If only one lesion was found, move the patient to a position where the reddened lesion remains free of pressure.

If the skin begins to crack, you should immediately contact a specialist, such as a family nurse or home care nurse, or, if necessary, a family doctor.

The choice of products for the care of pressure sores is very wide and for the right choice you need the help of a specialist. When choosing a care product, it is necessary to take into account the stages of development of a pressure ulcer (size, depth, presence of dead tissue, signs of infection, amount of discharge), its location, frequency of changing ulcer care products and patient preferences. If the caregiver does not have special training in caring for pressure ulcers, then it is not recommended to do the care on their own. Ask your Family Nurse and Home Care Nurse for advice and help! If the pressure sore has already arisen, then it can be cured as soon as possible in 2 weeks.If the pressure sore persists, you must definitely contact a specialist to assess the correctness of the treatment methods.

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Lamatiste astmed
Mõõtmine ja pildistamine
Lamatiste konservatiivne ravi

Figure 1. An example of correct body posture support with struts.

Figure 2. An example of the correct position of the body on a semi-lateral side using props

Figure 3.An example of a correct body position on the stomach and support of the position with the help of props

Figure 4. Example of correct lateral position with props

Figure 5. Example of correct and incorrect sitting position

Figure 6. An example of a raised headrest (30 degrees) and support of body position with props

Figure 7. Body Position to Avoid

Photo 1.An example of a pressure-distributing mattress

Photo 2. An example of a pressure-changing mattress (individual chambers are regularly filled with air and deflated after a certain time)

Photo 3. An example of a special Australian sheepskin

Photo 4. An example of a functional bed and its correct location in the ward, in which access to the patient is possible from three sides.

Photo 5. An example of a bed trapezium, with the help of which the patient can change his position in the bed.

Photo 6. An example of a sliding sheet with which you can easily move the patient (the bottom of the sheet is made of satin).

Information on reimbursement of medical aids and devices
The need and indications for the use of any medical aid compensated by the Health Insurance Fund are determined by the attending physician. After that, he writes out a digital card for a medical aid, with the help of which the patient buys the necessary drug at a discount either from a pharmacy or from a company that has an agreement with the Estonian Health Insurance Fund.Part of the support funds is compensated through another system – the Social Insurance system.

List of subsidized medical aids compensated by the Health Insurance Fund
NB! This list changes once a year! Further information can be obtained from the Health Insurance Fund (info phone 669 6630, e-mail: [email protected])

Basic principles of compensation by the Health Insurance Fund

Basic principles of compensation of aids from the social insurance system
On January 1, 2016, in accordance with the Social Security Act, the Social Insurance Department took responsibility for administering the compensation system for the sale and rental of medical aids

Further information can be obtained from the Social Insurance Board (info phone 16106 or 612136; e-mail: info @ sotsiaalkindlustusamet.ee)

Braden Scale for Predicting Pressure Sore Risk.

Chou, R., et al., Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness. Agency for Health Care Research and Quality Comparative Effectiveness Review No. 87.2013.

Coleman, S., et al., Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud, 2013.50 (7), 974-1003.

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel.(2009). Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel.

Ek, A.C., G. Gustavsson, and D.H. Lewis, The local skin blood flow in areas at risk for pressure sores treated with massage. Scand J Rehabil Med, 1985.17 (2), 81-86.

Gilcreast, D.M., et al., Research comparing three heel ulcer-prevention devices. J Wound Ostomy Continence Nurs, 2005. 32 (2), 112-120.

Guihan, M. and C.H. Bombardier, Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: a descriptive study.J Spinal Cord Med. 2003, 35 (4), 240-250.

Little, M.O., Nutrition and skin ulcers. Curr Opin Clin Nutr Metab Care 2009.16 (1) 39-49.

Pressure ulcer prevention: an evidence-based analysis. Ont Health Technol AssessSer, 2009.9 (2).

Shahin, E.S.M., T. Dassen, and R.J.G. Halfens, Pressure ulcer prevalence and incidence in intensive care patients: a literature review. Nursing in Critical Care, 2008. 13 (2), 71–79.

Anti-bedsore circles and bedsore pillows to the bed

Bedsores are severe skin lesions that appear on the body of patients with limited mobility.The buttocks, sides and tailbone are most susceptible to such wounds. They can appear on any part of the body, mainly over protruding bones (in the area of ​​elbows, heels, shoulder blades).

Special anti-decubitus pillows and circles in the bed help prevent the formation of bedsores . Among the main advantages of using such products are:

  • Reducing the risk of skin lesions;
  • Accelerated healing of existing pressure ulcers;
  • Possibility of using in patients with large body weight.

Anti-bedsore circles and pillows in the bed – an effective remedy for bedsores

Pressure ulcers do not respond well to therapy, so you need to do everything necessary to prevent their occurrence, because they cause pain and inconvenience to the patient. If a person lies on his back most of the time, then pressure ulcers appear on the shoulder blades, heels and the back of the head. Lying on your side causes wounds to your hips and knees. You can reduce the risk of their occurrence with the help of lining rubber circles, anti-decubitus foot holders, pillows for the head, legs, elbows and other parts of the body.

For the manufacture of such devices, special devices are used, the rollers are soft enough so as not to cause discomfort to bedridden patients. Anti-decubitus products make it possible to relieve damaged surfaces, promote healing of existing ones and prevent the formation of new bedsores. Special pillows reduce soft tissue compression. For example, anti-decubitus circles are placed so that the affected area is in the center – in weight and does not touch the bed.Most often they are used in the presence of bedsores on the tailbone and in the buttocks.

Anti-bedsore pillows can be used not only on beds, but also when patients are in wheelchairs. They evenly distribute the load on problem areas.

Special holders fix the desired part of the body on the weight, accelerating the healing of pressure ulcers.

All bedridden patients need such devices.

Treatment of pressure ulcers in the elderly

In bedridden patients, circulatory disorders often occur in immobile parts of the body.Later, as a result of these disorders, bedsores appear – areas of tissue necrosis. Often, lesions are formed in the region of the sacrum, lower back, scapular region, buttocks, and legs. Treatment of pressure ulcers in the elderly can be complicated by the rapid development of necrosis foci.

Prevention of pressure ulcers

The occurrence of pressure ulcers is facilitated by such factors as:

  • low mobility
  • overweight;
  • 90,046 old age;

  • diseases associated with circulatory disorders – cardiovascular diseases, diabetes, spinal cord injury.

In the treatment of pressure ulcers in our boarding house in Moscow, their prevention plays an important role. The bedridden patient must be given a massage. Particular attention is paid to those areas where circulatory disorders are most likely. Prevention of pressure sores includes careful monitoring of bed linen and daily hygiene procedures. The area of ​​the body, where pressure sores are often formed, are treated with an antiseptic. The use of a special anti-decubitus mattress is also effective.

Treatment of pressure ulcers in bedridden elderly: stages

There are four stages of pressure ulcer formation.

At the first stage, as such, there is still no ulcer, but swelling appears, redness of the skin – signs that signal a violation of blood circulation. During the treatment of bedsores in our boarding house in Moscow, at this stage, treatment with an antimicrobial agent is mandatory. To improve blood circulation, you need to massage the area. You can treat the skin with camphor alcohol – in addition to its antimicrobial effect, it irritates tissues and improves blood circulation, relieves inflammation.

If the pressure sore has already developed (stage 2), and a sore has appeared on the body, immediate treatment with an antiseptic and ointments that promote wound healing is necessary. Erosion of tissue at this stage has not yet had time to penetrate deeply into the tissue, therefore it heals well with proper treatment.

The third stage is considered to be a deeper lesion extending into the subcutaneous layer. In addition to local treatment with antiseptics, antibiotic therapy may be required (for symptoms of infection and general intoxication of the body) and pain relief if the patient is in pain.When treating pressure ulcers in older people at this stage, wounds already heal worse, and scars may form.

Stage 4 pressure ulcers are dangerous as joints and bones can be affected. The site of necrosis goes deep inside, the person experiences severe pain. In the case of dry necrosis, the affected area is limited to the bedsore itself. But if there is purulent discharge, this condition can be very dangerous. The spread of infection throughout the body can lead to sepsis, bone damage (periostitis).In the presence of a deep lesion, tissue is surgically removed or used to treat ointments with proteolytic enzymes, which cause rejection of the necrotic area.

Treatment and prevention of pressure ulcers at home

If a bedridden patient is at home, first of all, you need to monitor his hygiene. Caring for patients with pressure ulcers at home includes a daily change of bedding, wiping the body with water and an antiseptic. At least every 2 hours, it is necessary to change the position of the patient on the bed, ventilating the affected areas of the body.If necessary, a gauze bandage with an antiseptic is applied to the reddened and inflamed areas.

If you find areas of strong necrosis, suppuration of an ulcer during the treatment of pressure ulcers in the elderly, you should immediately call a doctor. This condition can be dangerous for the patient and lead to gangrene and sepsis.

Ointment for bedsores

For the treatment of pressure ulcers in Moscow and the Moscow region in bedridden elderly patients, local antiseptic, anti-inflammatory and analgesics are used, which improve blood circulation and promote wound healing.

  • All Menalind product line
  • Solcoseryl – improves metabolic processes in cells, promotes tissue regeneration.
  • Actovegin – helps to improve blood circulation and regeneration.
  • Algofin, Agrosulfan, Dermazin – antiseptic ointments against a wide range of infections.
  • Sulfargin is an antimicrobial agent that can be used to prevent the development of infection.
  • Levomekol, Levosin – antibacterial agents used in the presence of a purulent wound.