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Identifying Four Stages of a Bedsore

Have a loved one who is bedridden? Whether at home or in a nursing facility, it is imperative this person regularly change positions. In cases where a patient can’t help him or herself, “turning” insures pressure against the body is relieved, even for a short time. If possible, the person should sit up, stand or walk with assistance to avoid lying in one position in bed.

What causes a pressure sore?

Lying in the one position fosters pressure by way of friction with the mattress, wrinkled clothing or a tangled bed sheet. The heels of the foot, shoulder blades, tailbone and elbows are points where friction against the underside of the body is acute. Bedsores are caused by 1) pressure such as the compression from the force of bone against surface; 2) shear force when skin tissue or muscle sags with gravity or when the skin moves in one direction and the underlying bone in another, pinching a blood vessel, restricting blood flow and depriving a skin area of healing agents oxygen and nutrients or 3) friction, which may cause shedding of epidermis layers. Incontinence and perspiration contribute to bedsores as moisture breaks down bonds between cellular tissues which can break down the epidermis.

With prolonged, unrelieved pressure, sores develop. Commonly called bedsores, they are termed pressure ulcers or decubitus by doctors. These sores are defined and revised by the National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores.

Defining each stage

Stage One is referred to as superficial, where redness may occur and pain may be felt to the touch, although there is no skin tissue damage. Stage Two involves open wounds and damage to the epidermis and into but no deeper than the dermis. The sore is referred to as an abrasion or blister. Stage Three features a crater-like wound into but not through the subcutaneous skin layer. This layer has limited blood supply or circulation, so it becomes difficult to heal. With this stage, there may be more damage than apparent. Stage Four is the deepest wound, which extends into the muscle, tendon, joint or bone. Dead skin cells and wound fluid can mask the wound’s depth. According to the MayoClinic.com, Stage Four pressure sores are “extremely difficult to heal and can lead to lethal infections.”

There are two theories about pressure ulcer formation. The most accepted is the deep tissue injury theory, claiming ulcers begin deep near the bone and destroy tissue as they move outward toward the epidermis. The second theory contends skin deteriorates at the outer surface and moves deeper into the body.

When infection sets in

As with any open wound, controlling infection is at issue. Discharge of pus (bacterial, yellowish-white liquid) is a breeding ground for excess bacteria, especially in patients with weakened immune systems. Symptoms include fever, pain, skin redness, skin warmth and odor. Antiseptics are recommended but hydrogen peroxide is not. Bandage dressings should be changed frequently For patients with Stages One and Two ulcers, the wound care team should use guidelines established by the American Medical Directors Association (AMDA) for treatment of these lower-grade sores.

Extreme cases

For those with Stage Three or Stage Four sores, surgery such as a tissue flap, skin graft or other closure methods may be necessary to counter anemia, gangrene or sepsis. Gas gangrene can produce toxins that completely destroy muscle tissue. Sepsis occurs after bacteria from a massive infection (Stage Four) enters the blood and spreads rapidly, possibly causing shock as well as organ failure.

New treatment

A more recent intervention is negative pressure wound therapy, which is the application of topical negative pressure to the wound. This technique, developed by scientists at Wake Forest University, uses foam placed into the wound cavity which is then covered in a film which creates an airtight seal. Once this seal is established, the technician is able to remove pus and other infectious materials in addition to aiding the body to produce tissue for the creation of new skin layers.

Always be vigilant

In the most severe case (someone with paralysis) pain from the development of a pressure sore cannot be sensed. With no warning signals, the patient doesn’t know to shift their position in bed. For smokers, their ability to physically fight a pressure sore is compromised since nicotine impairs blood flow and reduces oxygen in the bloodstream. Older individuals tend to have thinner skin and are susceptible to physical injury from pressure, friction or shear on the body. They weigh less, meaning there is less muscle or fatty tissue surrounding bones. If someone has poor nutrition, their skin and blood vessels are weakened, making them vulnerable to wound formation. The healing and re-growth rate of skin cells declines in an elderly person who may be fighting a pressure sore.


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The information you obtain at this site is not, nor is it intended to be, legal advice.
You should consult an attorney for individual advice regarding your own situation.