Pressure Ulcers

What are pressure ulcers?

A pressure ulcer (also called a bed sore, pressure sore, or decubitus ulcer) is an area of injured skin and tissue. Pressure ulcers develop from sitting or lying in one position for too long. When a person does not change positions often enough, extra pressure is put on certain areas of the body. Pressure ulcers also can develop from sliding down in a chair or in bed, or being dragged across a bed sheet —  movements that result in what is called "shearing and friction."

Who is most likely to get pressure ulcers?

People at greater risk of getting pressure ulcers are those who spend a lot of time in a bed, chair, or wheelchair. Others at risk include:

• People who cannot move or change positions without someone else’s help, including those who are in a coma, paralyzed, or have had a hip fracture
• People who have problems controlling their bowel or bladder functions
• People who do not eat a balanced diet
• People who have a lowered mental awareness caused by a medical condition, medicines or anesthesia. (When mental awareness is lowered, a person might not be able to act to prevent the development of pressure ulcers.)
• People who have a lowered overall health status

Where on the body do pressure ulcers usually form?

Pressure ulcers occur more often over bony parts of the body because there is more pressure on the skin over these bony areas and less fat to cushion the area. The illustrations on the right show these most common body sites. You and your caregiver should pay attention to these areas when inspecting your skin for signs of pressure ulcers.

Can pressure ulcers be prevented?

Yes. Here are some ways you can help prevent pressure ulcers from forming:

Keep the skin clean — Use a gentle cleanser made for this purpose (not soaps, which dry the skin). Dry the skin by patting — not rubbing —  Before anyone treats or touches the skin/wound area, make sure the person washes his or her hands.

Keep the skin from drying out — Apply a cream moisturizer (for example, Eucerin, Neutrogena) immediately after a bath or shower to seal in the moisture from bathing.

Eat healthy foods — Proper nutrition is vital to healing. Poor eating habits result in delayed healing, increased length of hospital stay, and increased risk of infection. Your body, in fact, requires extra calories to help heal wounds. Eating foods high in calories and protein — such as cheese, peanut butter, chicken, beef, and fish — is important. In addition to a balanced diet, talk with your health care providers (doctors, nurse, dietitian) about the need for vitamins, extra minerals, or other nutritional supplements.

Protect the skin from too much moisture — When skin gets too wet — a condition called maceration — it is more likely to break down. Skin can become too moist when sweat, urine, feces, or wound drainage remain in direct contact with the skin. If your moisture problem is caused by a bowel or bladder control problem, make sure:

• The skin is cleaned as soon as it becomes soiled with urine or stool
• A moisture barrier cream is used to protect the skin from body fluids
• Absorbent pads or underwear with a quick-drying surface are used to help keep moisture away from the skin

If pressure ulcers do form, they do not have to get worse. Treatment of pressure ulcers consists of relieving the pressure that caused the sore, treating the sore itself, and improving eating habits and other conditions to help the sore heal.

Tips for proper positioning and movement in bed

If you must stay in bed:

• Inspect your skin at least once a day.
• Change position at least every two hours. (If you are unable to change positions by yourself, ask for assistance.)
• Keep a written "turning schedule" to record when your body position was last changed as well as a note of your last position.
• Shift your weight slightly every 15 minutes, if you can.
• Use your arms to lift yourself rather than dragging yourself onto the bed or chair. If in a hospital bed, use the trapeze bar to help lift your body to reposition.
• Avoid lying directly on your hip bone when lying on your side. A 30 degree side-lying position is best. To accomplish this, tuck pillows under one side so that your weight rests on the fleshy part of your buttock instead of your hip bone.
• Raise the head of the bed as little as possible (no more than 30 degrees from horizontal) for as short a time as possible to avoid sliding down in the bed. The head of the bed can be raised during meals to prevent choking. Return the head of the bed to a horizontal or semi-reclining position one hour after eating.)
• When lying on your back, keep your heels up off the bed by placing a thin foam pad or pillow  under your legs from the middle of your calf to your ankle.

Position the pillow length-wise, as shown.

Do NOT place the pad or pillow directly--and only--under the knees because this could reduce blood flow to the lower leg.

• Use pillows or small foam wedge pads to keep knees and ankles from touching each other.
• Keep linens as wrinkle-free as possible.
• Let your health care provider know if the bed linens are soiled so that they can be changed.

Tips for proper positioning and movement in chairs

If you must stay in a chair or wheelchair:

• Inspect your skin at least once a day.
• Always use a seat cushion designed to relieve pressure on sitting surfaces. Ask your health care provider about proper foam or air cushion product(s) to use. (Avoid donut-shaped cushions, since these reduce blood flow to the tissue, causing tissue to swell.)
• Change position every hour. (If you are unable to change positions by yourself, ask for assistance or have someone help you back to bed so you can change positions.)
• Lift yourself up off the chair every 15 minutes. Depending on your strength, use one of the three methods described below (listed from most to least preferred) and hold the position for at least a slow count of five to 10 seconds:
  1. Place your hands on the arm rest and lift your body off the chair.
  2. Press your elbow on the arm rest to lift that side of your body off the chair; repeat on opposite side, or do both sides at the same time.
  3. Shift your weight by leaning far over to one side and repeat on the opposite side.
• Keep the top of your thighs slightly sloping forward and use pillows or foam cushions to keep knees and ankles from touching each other.
• Rest your feet comfortably on the floor or on the footrest.
• Rest your elbows, forearms, and wrists on the chair arm supports.

If a pressure ulcer forms, how long does it last?

Pressure ulcers should always be treated by trained health care personnel. With proper care and treatment, a pressure ulcer should begin healing within two weeks.

Where can I get more information about pressure ulcers?

The following organizations provide information for people concerned about pressure ulcers.

Wound/Ostomy/Continence Nurses Society
This organization refers patients to local nurses who are trained in treating and preventing pressure ulcers.

4700 W. Lake Ave.
Glenview, IL 60025
888-224-9626
www.wocn.org

National Pressure Ulcer Advisory Panel
This group offers information for caregivers, families providing care at home, and others concerned about pressure ulcers.

12100 Sunset Hills Road, Suite 130
Reston, VA 20190
703-464-4849
www.npuap.org

Agency for HealthCare Research and Quality
This government agency offers free informational pamphlets and guidelines on various health care topics.

540 Gaither Road
Rockville, MD 20850
301-427-1364
www.ahrq.gov/

Signs that a pressure ulcer is forming

• The skin around the area will be red and shiny or dark purple. (In dark-skinned people, the area might simply become darker than normal.)
• The skin might be warm to the touch compared with nearby tissue.
• The area might also be swollen or hard, and might lack feeling

Note: Skin reddening that disappears after pressure is removed is normal and is not a pressure ulcer. Discoloration of the skin that is constant might be a pressure ulcer.)

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 2/15/2005