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Treating Pressure Sores

What Is a Pressure Sore?

A pressure sore (or bed sore) is an injury to the skin and tissue under it. Pressure sores are usually caused by unrelieved pressure. If you sit or lie in the same position for a long time, the pressure on a small area of the body can squeeze shut tiny blood vessels that normally supply tissue with oxygen and nutrients. If tissue is starved of these "fuels" for too long, it begins to die, and a pressure sore starts to form.

Pressure sores are called pressure ulcers and decubitus ulcers as well as bed sores. How serious they are depends on the amount of damage to skin and tissue. Damage can range from a change in the color of unbroken skin (Stage I) to severe, deep wounds down to muscle or bone (Stage IV) (see Figure 1). In light-skinned people, a Stage I sore may change skin color to a dark purple or red area that does not become pale under fingertip pressure. In dark-skinned people, this area may become darker than normal. The affected area may feel warmer than surrounding tissue.

Purpose of This Article

A pressure sore is serious. It must not be ignored. With proper treatment, most pressure sores will heal. Healing depends on many things: your general health, diet, relieving pressure on the sore, and careful cleaning and dressing of the sore. Share this booklet with your family members and caregivers. By working with health care professionals and following these guidelines, you and your caregiver can better treat pressure sores and prevent new ones.

This article will help you and your caregiver care for pressure sores. It also gives basic information about preventing new sores. This artcile gives the steps essential to helping a pressure sore heal. Although not all steps apply to everyone, it is important that you:

  • Learn how to prevent and treat pressure sores.
  • Ask questions if you do not understand.
  • Explain your needs and concerns.
  • Know what is best for you.
  • Be active in your care.

Treatment

Healing a pressure sore is a team effort. A team of health care professionals will work with you to prepare a treatment plan. Your team may include doctors, nurses, dietitians, social workers, pharmacists, and occupational and physical therapists. However, you and your caregiver are the most important team members. Feel free to ask questions or share concerns with other team members.

Your Role

You and your caregiver need to:

  • Know your roles in the treatment program.
  • Learn how to perform the care.
  • Know what to report to the doctor or nurse.
  • Know how to tell if the treatment works.
  • Help change the treatment plan when needed.
  • Know what questions you want to ask.
  • Get answers you understand.

Treatment Plan

To develop a treatment plan that meets your needs, the doctor or nurse must know about:

  • Your general health.
  • Illnesses that might slow healing (such as diabetes or hardening of the arteries).
  • Prescription or over-the-counter medicines you take.
  • The emotional support and physical assistance available from family, friends, and others.

Your doctor or nurse will perform a physical exam and check the condition of your pressure sore to decide how to care for it. If you have had a pressure sore before, tell the doctor or nurse what helped it heal and what didn't help.

Your emotional health is also important. Be sure to share information about stresses in your life as well as health beliefs and practices. This will help your care team design a treatment plan that meets your personal needs.

The treatment plan will be based on the results of your physical exam, health history, personal circumstances, and the condition of the sore (how it looks). This plan will include specific instructions for:

  • Taking pressure off the sore.
  • Caring for the pressure sore by cleaning the wound, removing dead tissue and debris, and dressing or bandaging the area to protect it while it heals.
  • Aiding healing by making sure you get enough calories, protein, vitamins, and minerals.

Note to Caregivers

Although patients should be as active in their care as possible, you may need to provide much or all of their care. As a result, you may find you have questions or problems. If so, ask for help. Call doctors, nurses, and other professionals for answers and other support.

Remember that patients who must be in a bed or chair for long periods don't have to get pressure sores. Pressure sores can be prevented. And sores that have formed can be healed.

Helping Pressure Sores Heal

Healing pressure sores depends on three principles: pressure relief, care of the sore, and good nutrition.

Pressure Relief

Pressure sores form when there is constant pressure on certain parts of the body. Long periods of unrelieved pressure cause or worsen pressure sores and slow healing once a sore has formed. Taking pressure off the sore is the first step toward healing.

Pressure sores usually form on parts of the body over bony prominences (such as hips and heels) that bear weight when you sit or lie down for a long time. Figure 2 shows "pressure points" where sores often form.

You can relieve or reduce pressure by:

  • Using special surfaces to support your body.
  • Putting your body in certain positions.
  • Changing positions often.

Support surfaces

Support surfaces are special beds, mattresses, mattress overlays, or seat cushions that support your body in bed or in a chair. These surfaces reduce or relieve pressure. By relieving pressure, you can help pressure sores heal and prevent new ones from forming.

You can get different kinds of support surfaces. The best kind depends on your general health, if you are able to change positions, your body build, and the condition of your sore. You and your doctor or nurse can choose the surface best for you.

One way to see if a support surface reduces pressure enough is for the caregiver to do a "hand check" under the person (Figure 3). The caregiver places his or her hand under the support surface, beneath the pressure point, with the palm up and fingers flat. If there is less than 1 inch of support surface between the pressure point of the body and the caregiver's hand, the surface does not give enough support. If you need more support, your doctor or nurse will recommend a different support surface.

Caregivers should know that pressure sores are often painful, and a hand check may increase pain. Caregivers should ask if it will be okay to do a hand check, which should be done as gently as possible.

Good body positions

Your position is important to relieving pressure on the sore and preventing new ones. You need to switch positions whether you are in a bed or a chair.

In bed. Follow these guidelines:

  • Do not lie on the pressure sore. Use foam pads or pillows to relieve pressure on the sore, as shown in Figure 4.
  • Change position at least every 2 hours.
  • Do not rest directly on your hip bone when lying on your side. A 30-degree side-lying position is best (see Figure 4).
  • When lying on your back, keep your heels up off the bed by placing a thin foam pad or pillow under your legs from midcalf to ankle (Figure 5). The pad or pillow should raise the heels just enough so a piece of paper can be passed between them and the bed. Do not place the pad or pillow directly under the knee when on your back, because this could reduce blood flow to your lower leg.
  • Do not use donut-shaped (ring) cushions-they reduce blood flow to tissue.
  • Use pillows or small foam pads to keep knees and ankles from touching each other.
  • Raise the head of the bed as little as possible. Raise it no more than 30 degrees from horizontal (Figure 6). If you have other health problems (such as respiratory ailments) that are improved by sitting up, ask your doctor or nurse which positions are best.
  • Use the upright position during meals to prevent choking. The head of the bed can be moved back to a lying or semi-reclining position 1 hour after eating.

In a chair or wheelchair. When sitting, you should have good posture and be able to keep upright in the chair or wheelchair (Figure 7). A good position will allow you to move more easily and help prevent new sores.

For your specific needs, use cushions designed to relieve pressure on sitting surfaces. Even if pressure can be relieved with cushions, your position should be changed every hour. Remember to:

  • Avoid sitting directly on the pressure sore.
  • Keep the top of your thighs horizontal and your ankles in a comfortable, "neutral" position on the floor or footrest (Figure 7). Rest your elbows, forearms, and wrists on arm supports.
  • If you cannot move yourself, have someone help you change your position at least every hour. If you can move yourself, shifting your weight every 15 minutes is even better.
  • If your position in a chair cannot be changed, have someone help you back to bed so you can change position.
  • Do not use donut-shaped or ring cushions, because they reduce blood flow to tissue.

Changing positions

Change your body position often-at least every hour while seated in a chair and at least every 2 hours while lying in bed. A written turning schedule or a turn clock (with positions written next to times) may help you and your caregiver remember turning times and positions. You may want to set a kitchen timer.

Be sure your plan works for you. It should consider your skin's condition, personal needs and preferences, and your comfort level.

Pressure Sore Care

The second principle of healing is proper care of the sore. The three aspects of care are:

  • Cleaning.
  • Removing dead tissue and debris (debridement).
  • Dressing (bandaging) the pressure sore.

Pressure sore care is summarized in Table 1.

You should know about sore care even if only your caregiver is caring for the sore. Knowing about your care will help you make informed decisions about it.

1. Cleaning

Pressure sores heal best when they are clean. They should be free of dead tissue (which may look like a scab), excess fluid draining from the sore, and other debris. If not, healing can be slowed, and infection can result.

A health care professional will show you and your caregiver how to clean and/or rinse the pressure sore. Clean the sore each time dressings are changed.

Cleaning usually involves rinsing or "irrigating" the sore. Loose material may also be gently wiped away with a gauze pad. It is important to use the right equipment and methods for cleaning the sore. Tissue that is healing can be hurt if too much force is used when rinsing. Cleaning may be ineffective if too little force is used.

Use only cleaning solutions recommended by a health care professional. Usually saline is best for rinsing the pressure sore. Saline can be bought at a drug store or made at home (Table 2).

Caution: Sometimes water supplies become contaminated. If the health department warns against drinking the water, use saline from the drug store or use bottled water to make saline for cleaning sores.

Do not use antiseptics such as hydrogen peroxide or iodine. They can damage sensitive tissue and prevent healing.

Cleansing methods are usually effective in keeping sores clean. However, in some cases, other methods will be needed to remove dead tissue.

2. Removing dead tissue and debris

Dead tissue in the pressure sore can delay healing and lead to infection. Removing dead tissue is often painful. You may want to take pain-relieving medicine 30 to 60 minutes before these procedures.

Under supervision of health care professionals, dead tissue and debris can be removed in several ways:

  • Rinsing (to wash away loose debris).
  • Wet-to-dry dressings. In this special method, wet dressings are put on and allowed to dry. Dead tissue and debris are pulled off when the dry dressing is taken off. This method is only used to remove dead tissue; it is never used on a clean wound.
  • Enzyme medications to dissolve dead tissue only.
  • Special dressings left in place for several days help the body's natural enzymes dissolve dead tissue slowly. This method should not be used if the sore is infected. With infected sores, a faster method for removing dead tissue and debris should be used.

Qualified health care professionals may use surgical instruments to cut away dead tissue.

Based on the person's general health and the condition of the sore, the doctor or nurse will recommend the best method for removing dead tissue.

3. Choosing and using dressings

Choosing the right dressings is important to pressure sore care. The doctor or nurse will consider the location and condition of the pressure sore when recommending dressings.

The most common dressings are gauze (moistened with saline), film (see-through), and hydrocolloid (moisture- and oxygen-retaining) dressings. Gauze dressings must be moistened often with saline and changed at least daily. If they are not kept moist, new tissue will be pulled off when the dressing is removed.

Unless the sore is infected, film or hydrocolloid dressings can be left on for several days to keep in the sore's natural moisture.

The choice of dressing is based on:

  • The type of material that will best aid healing.
  • How often dressings will need to be changed.
  • Whether the sore is infected.

In general, the dressing should keep the sore moist and the surrounding skin dry. As the sore heals, a different type of dressing may be needed.

Storing and caring for dressings

Clean (rather than sterile) dressings usually can be used, if they are kept clean and dry. There is no evidence that using sterile dressings is better than using clean dressings. However, contamination between patients can occur in hospitals and nursing homes. When clean dressings are used in institutions, procedures that prevent cross-contamination should be followed carefully.

At home, clean dressings may also be used. Carefully follow the methods given below on how to store, care for, and change dressings.

To keep dressings clean and dry:

  • Store dressings in their original packages (or in other protective, closed plastic packages) in a clean, dry place.
  • Wash hands with soap and water before touching clean dressings.
  • Take dressings from the box only when they will be used.
  • Do not touch the packaged dressing once the sore has been touched.
  • Discard the entire package if any dressings become wet or dirty.

Changing dressings. Ask your doctor or nurse to show how to remove dressings and put on new ones. If possible, he or she should watch you change the dressings at least once.

Ask for written instructions if you need them. Discuss any problems or questions about changing dressings with the doctor or nurse.

Wash your hands with soap and water before and after each dressing change. Use each dressing only once. You should check to be sure the dressing stays in place when changing positions. After the used dressing is removed, it must be disposed of safely to prevent spread of germs that may be on dressings.

Using plastic bags for removal. A small plastic bag (such as a sandwich bag) can be used to lift the dressing off the pressure sore (Figure 8). Seal the bag before throwing it away. If you use gloves, throw them away after each use.

Good Nutrition

Good nutrition is the third principle of healing. Eating a balanced diet will help your pressure sore heal and prevent new sores from forming.

You and your doctor, dietitian, or nurse should review any other medical conditions you have (such as diabetes or kidney problems) before designing a special diet.

Weigh yourself weekly. If you find you cannot eat enough food to maintain your weight or if you notice a sudden increase or decrease, you may need a special diet and vitamin supplements. You may need extra calories as part of a well-balanced diet.

Tell your doctor or nurse about any weight change. An unplanned weight gain or loss of 10 pounds or more in 6 months should be looked into.

Pain and Infection

Even if you care for your pressure sore properly, problems may come up. Pain and infection are two such problems. Pain can make it hard to move or to participate in care. Infection can slow healing.

Managing Pain

You may feel pain in or near the pressure sore. Tell your doctor or nurse if you do. Covering the sore with a dressing or changing your body position may lessen the pain.

If you feel pain during cleaning of the pressure sore or during dressing changes, medicine may help. It may be over-the-counter or prescription medicine. Take medicine to relieve pain 30 to 60 minutes before these procedures to give it time to work. Tell your doctor or nurse if your pain medicine does not work.

Treating Infection

Healing may slow if the sore becomes infected. Infection from the sore can spread to surrounding tissue (cellulitis), to underlying bone (osteomyelitis), or throughout the body (sepsis). These serious complications demand immediate medical attention. If you note any of the signs of infection in Table 3, call your doctor right away.

Checking Your Progress

A health care professional should check your pressure sore regularly. How often depends on how well the sore is healing. Generally, a pressure sore should be checked weekly.

Examining the Sore

The easiest time to check pressure sores is after cleaning. Signs of healing include decreased size and depth of the sore and less drainage. You should see signs of healing in 2 to 4 weeks. Infected sores may take longer to heal.

Signs to Report

Tell your doctor or nurse if:

  • The pressure sore is larger or deeper.
  • More fluid drains from the sore.
  • The sore does not begin to heal in 2 to 4 weeks.
  • You see signs of infection (see Table 3).

Also report if:

  • You cannot eat a well-balanced diet.
  • You have trouble following any part of the treatment plan.
  • Your general health becomes worse.

Changing the Treatment Plan

If any of these signs exist, you and your health care professional may need to change the treatment plan. Depending on your needs, these factors may be changed:

  • Support surfaces.
  • How often you change how you sit or lie.
  • Methods of cleaning and removing dead tissue.
  • Type of dressing.
  • Nutrition.
  • Infection treatment.

Other Treatment Choices

If sores do not heal, your doctor may recommend electrotherapy. A very small electrical current is used to stimulate healing in this procedure. This is a fairly new treatment for pressure sores. Proper equipment and trained personnel may not always be available.

If your pressure sore is large or deep, or if it does not heal, surgery may be needed to repair damaged tissue. You and your doctor can discuss possible surgery.

Care of Healthy Skin

Having healthy skin is important to preventing future pressure sores. Healthy skin is less likely to be damaged and heals faster than skin in poor condition.

You can help prevent new pressure sores while helping to heal the ones you have. To improve your skin's health:

  • Bathe when needed for cleanliness and comfort.
  • Use mild soap and warm (not hot) water.
  • Apply moisturizers (such as skin lotions) to keep skin from becoming too dry.

Inspect your skin at least once a day for redness or color changes or for sores. Pay special attention to pressure points where pressure sores can form (Figure 2).

Skin problems can also result from bladder or bowel leakage (urinary or fecal incontinence). If you have these problems, ask your doctor or nurse for help. If the leakage cannot be controlled completely:

  • Clean your skin as soon as it becomes soiled.
  • Use a protective cream or ointment on the skin to protect it from wetness.
  • Use incontinence pads and/or briefs to absorb wetness away from the skin.

For more detailed information about how to prevent pressure sores, see the ElderCare Online's article Preventing Pressure Sores.

For More Information

Information in this article is based on Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. It was developed by a non-Federal panel sponsored by the Agency for Health Care Policy and Research (AHCPR), an agency of the Public Health Service. Other guidelines on common health problems are available, and more are being developed.

For more information about these and other guidelines call:

(800)358-9295 (toll free)
          or write to:
Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907

Be Active in Your Care

If you understand the basic ideas of pressure relief, sore care, and good nutrition, you can take the steps needed to heal pressure sores and prevent new ones. Not all steps apply to every person. The best program will be based on your needs and the condition of your sores.

Be sure to:

  • Ask questions.
  • Explain your needs, wants, and concerns.
  • Understand what is being done and why.
  • Know what is best for you. Discuss what you can do to prevent and treat pressure sores-at home, in the hospital, or in the nursing home.

Being active in your care can mean better care.

Additional Resources

The following organizations offer a variety of resources for people concerned about pressure sores.

Booklets and information for patients, caregivers, and families providing care at home:

National Pressure Ulcer Advisory Panel (NPUAP) SUNY at Buffalo Beck Hall 3435 Main Street Buffalo, NY 14214 (716) 881-3558

Referrals to local Enterostomal Therapy Nurses:

Wound Ostomy and Continence Nurses Society (WOCN) (Formerly the International Association of Enterostomal Therapy) 27241 La Paz Road Suite 121 Laguna Niguel, CA 92656 (714) 476-0268

Information about nutrition:

National Center for Nutrition and Dietetics (NCND) Consumer Hotline (toll-free): (800) 366-1655

U.S. Department of Health and Human Services Public Health Service: Agency for Health Care Policy and Research Executive Office Center, Suite 501 2101 East Jefferson Street Rockville, MD 20852

[Tables]

Table 1. Basic Steps of Pressure Sore Care

Task

Steps
Prepare
  1. Wash hands with soap and water.
  2. Get supplies: saline; irrigation equipment (syringe or other device, basin, large plastic bag); dressings and tape; disposable plastic gloves and small plastic [sandwich] bag; towel; glasses, goggles, and plastic apron (optional).
  3. Move patient into comfortable position
  4. Place large plastic bag on bed to protect bed linen.
Remove dressing
  1. Place hand into small dressing plastic bag (see Figure 8)
  2. Grasp old dressing with bag-covered hand and pull off dressing.
  3. Turn bag inside-out over the old dressing.
  4. Close the bag tightly before throwing it away.
Irrigate sore
  1. Put on disposable plastic sore gloves. (Wear glasses or goggles and plastic apron if drainage might splash.)
  2. Fill syringe or other device with saline.
  3. Place basin under pressure sore to catch drainage
  4. Hold irrigation device 1 to 6 inches from sore and spray it with saline.
  5. Use enough force to remove dead tissue and old drainage, but not damage new tissue.
  6. Carefully remove basin so fluid doesn't spill.
  7. Dry the skin surrounding the sore by patting skin with soft, clean towel.
  8. After assessing and dressing the sore, remove gloves by pulling them inside out. Throw away gloves properly.
Assess sore
  1. Assess healing. As sore sore heals, it will slowly become smaller and drain less. New tissue at the bottom of the sore is light red or pink and looks lumpy and glossy. Do not disturb this tissue.
  2. Tell health care provider if the sore is larger, drainage increases, the sore is infected, or there are no signs of healing in 2 to 4 weeks.
Dressing the sore Place a new dressing over the sore as instructed by the doctor or nurse.
Remember to:
  • Use dressings only once.
  • Keep dressings in the original package or other closed plastic package.
  • Store dressings in a clean, dry place.
  • Throw out the entire package if any dressings get wet, contaminated, or dirty.
  • Wash your hands before touching clean dressings.
  • Do not touch packaged dressings once you touch the sore.

Table 2. Recipe for Making Saline (Salt Water)

  1. Use 1 gallon of distilled water or boil 1 gallon of tap water for 5 minutes. Do not use well water or sea water.
  2. Add 8 teaspoons of table salt to the distilled or boiled water.
  3. Mix the solution well until the salt is completely dissolved. Be sure storage container and mixing utensil are clean (boiled).

Note: Cool to room temperature before using. This solution can be stored at room temperature in a tightly covered glass or plastic bottle for up to 1 week.

Table 3. Signs of Infection

Infected Sore

Widespread Infection
Thick green or yellow drainage Fever or chills
Foul odor Weakness
Redness or warmth around sore Confusion or difficulty concentrating
Tenderness of surrounding area Rapid heart beat
Swelling  

[Figures]

Figure 1. Pressure Sore Stages

 

Figure 2. Pressure Points

Figure 3. Hand Check to Assess Pressure Relief

 

Figure 4. Best Position While on Side

 

Figure 5. Keep Heels off Bed

 

Figure 6. Head of Bed Raised 30 Degrees

 

Figure 7. Best Position While Sitting

 

Figure 8. Plastic Bag Method of Removing Bandages

Source: Agency for Health Care Policy and Research Publication No. 95-0654 December 1994

Available from ElderCare Online™                  www.ec-online.net                 ©1999 Prism Innovations, Inc.