Pressure Injuries

What are pressure injuries?

Pressure injuries are areas of skin damage caused by a lack of blood flow. You may also hear them called bedsores, pressure sores, or pressure ulcers. The skin in the area can die and leave an open sore (ulcer).

The decreased blood flow and resulting damage are due to pressure. The pressure is combined with rubbing (friction), moisture, changed blood flow patterns, and pulling on the skin. Pressure injuries often occur over bony parts of the body. These include the hips, heels, the base of the spine (tailbone), shoulder blades, the backs and sides of the knees, and the back of the head.

What causes pressure injuries?

Pressure injuries can occur when you are restricted to a bed or chair and don’t change positions on a regular basis. When you rarely move, your body weight limits the blood flow to your arms, legs, neck, and back. The lack of blood flow to the skin and tissues under the skin may cause them to break down until a sore appears.

Who is at risk for pressure injuries?

People at greatest risk for this type of injury are those who use wheelchairs for much of the day, or those who must stay in bed for long periods of time. Pressure injuries often occur on parts of the body where the skin is mashed between a bone and a surface such as a wheelchair or mattress. Pressure injuries can develop quickly, sometimes in just a few hours without movement.

Pressure injuries are most likely to occur in older adults, particularly those who live in nursing homes. Studies show that more than 1 in 10 nursing home residents have had a pressure injury.

People are also at greater risk for pressure injuries if they:

Have a long-term (chronic) illness such as diabetes
Don’t have adequate nutrition (undernourished)
Smoke
Have fragile skin

If found and treated quickly, pressure injuries should heal in a few weeks. But if left untreated, they can quickly worsen.

What are the symptoms of pressure injuries?

Pressure injuries start as red, blue, or purplish patches on the body that don't turn white when touched and get worse over time. These patches can quickly turn into blisters and open sores. The sores can then become infected and grow deeper until they reach muscle, bone, or joints.

Pressure injuries are found on parts of the skin that are closest to bone and have little fat to pad them. This includes the heels, hips, elbows, ankles, back, base of the spine, and shoulders. The affected skin may feel warm, smell bad, and look swollen. A fever, chills, or confusion can develop if the infection spreads to the bloodstream. If untreated, a very serious condition called septic shock can occur.

In the worst cases, pressure injuries can become life-threatening. That's why it's vital to contact a healthcare provider at the first sign of a pressure injury. This is often a soft, red patch of skin that stays red for 30 minutes even after the pressure is eased. People with dark skin tones should call a healthcare provider if a patch of skin turns darker or is warm to the touch.

How are pressure injuries diagnosed?

Healthcare providers working with people in the hospital can spot pressure injuries. So can health aides helping with cleansing and dressing. If you are restricted to bed at home, watch for any reddish patches or sores on your body. Ask family and friends who visit to check for an injury to bony areas and other areas.

Pressure injuries are organized into different categories. They range from an early warning signal to the most severe:

Stage 1. A red, blue, or purplish area first appears like a bruise on the skin. It may feel warm to the touch and burn or itch.
Stage 2. The bruise becomes an open sore that looks like an abrasion or blister. The skin around the wound can be discolored. The area is painful.
Stage 3. The sore deepens and looks like a crater. There are often dark patches of skin around the edges.
Stage 4. The damage spreads to the muscle, bone, or joints. It can cause a serious bone infection called osteomyelitis. It can also lead to a possibly life-threatening blood infection called sepsis.
Unstageable full thickness pressure injury. A stage 3 or 4 injury that is covered with black dead tissue (eschar) or creamy yellow, gray/black, or white, thick slimy tissue (slough). It is difficult to see the severity of the injury because of the covering.
Deep tissue pressure injury. A very dark red, maroon, or purple colored area of the skin that doesn't disappear when pressed on or a dark deep wound or blister filled with blood that is seen through a separation in the skin.

How are pressure injuries treated?

Bedsores should be treated right away, even in the early stages. That’s because they can quickly get worse. Prop up the leg or area near the injured body part with a pillow or foam cushion. This will help relieve pressure on the area so it can start to heal. Areas at risk for friction can be powdered with plain talc to help. There are also special dressings that can be applied to protect the area from further damage. Ask your healthcare provider which devices and materials are best for you.

If the injury has become an open sore, follow a healthcare provider’s instructions on how to clean the area to prevent infection. Generally, pressure injuries are cleaned with saline or saltwater to remove dead tissue. In some cases, surgery is required to remove the dead tissue. The injury may also be covered with a special bandage. A healthcare provider can prescribe special dressings and therapies that speed up skin healing.

Nutrition plays an important role in healing pressure injuries. To heal correctly, the body needs enough calories, protein, and nutrients such as vitamin C and zinc. In some cases, supplements are needed to promote healing.

The most severe sores may require a hospital stay to fight infection or surgery may be needed to add muscle flaps or skin grafts.

Can pressure injuries be prevented?

If on bed rest. To prevent pressure injuries, ease pressure on the skin by changing your body position at least every 2 hours. Check to make sure that the bedding is smooth and that one leg isn't lying on top of the other. Put a pillow between your legs if lying on one side. Raise your heels slightly off the mattress with a pad or foam underneath the lower legs (don’t use doughnut-shaped pads).

If using a wheelchair. Shift positions every 10 to 15 minutes. If that isn't possible, have someone move you at least once an hour. If you have a neuromuscular disease, it may be helpful to shift to a standing wheelchair at certain times. This can ease the pressure on your buttocks. Doing wheelchair "pushups" can also help.

If you are immobile or are caring for someone who is. Think about buying an alternating air mattress. This can greatly reduce the pressure against the skin. This type of mattress has cells that alternately inflate and deflate to increase blood circulation. You might also ask your healthcare provider about new technologies to find pressure injuries. Check with your insurance company or Medicare to see what is covered.

If lifting someone who is immobile. Use sheets or a harness or lifting device rather than pulling on the person's arms or legs. This is because skin is often fragile and easily injured.

Here are other good habits that can help:

Take good care of skin in general. Wash soiled areas right away with warm (not hot) water and soap. Moisturize dry skin. It's also vital to keep skin warm and dry. Too much moisture can increase the risk for skin infection.
Eat a well-balanced diet and drink 8 to 10 cups of water a day. This will help keep you hydrated and keep blood flowing correctly, which helps prevent sores from forming.
If possible, exercise daily. If you are immobile, ask caregivers to move your limbs gently to exercise them.
Don’t smoke. And stay away from secondhand smoke. This is also important for wound healing and optimal health.

Key points about pressure injuries

Pressure injuries are areas of skin damage caused by a lack of blood flow. They are also called bedsores, pressure sores, or pressure injuries.
They can occur when you are restricted to a bed or chair and don’t change positions on a regular basis.
The skin in the area can die and leave an open sore.
They often develop over bony parts of the body such as the hips, heels, base of the spine, shoulder blades, and back of the head.
It’s important to get treatment right away, even in the early stages, because the sores can quickly get worse.
The most severe sores may require a hospital stay to fight infection. In some cases, surgery may be needed.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.