A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months. He’s diabetic and has lost feeling in the bottom of his feet. He’s had these pressure sores in the past but has trouble getting them to heal up.
Pressure sore: Areas of skin that have been damaged by pressure such as sitting or lying in one position for a very long period of time. They can also be called “bedsores.” The are more commonly found in areas of the body where the bone is near the surface of the skin such as on the hips, elbows, ankles and back/buttocks. The skin and soft tissues become damaged because not enough oxygenated blood can get to the area to promote healing usually due to the compression of the damaged skin and soft against hard bone tissue.
Appearance: The sores change in the way they look depending on how long they’ve been present and how much damage has been done. In the beginning, the sore appears as a small red patch of skin, and if not treated, the skin will break down and cause a hole or crater to form (we call this an ulcer).
Stage 1: The skin is intact without ulcers but when you push on the skin it does not change colors to indicate good blood flow. Usually, healthy tissue will be pink and when you push on the area with your finger you can notice it will become less pink and in a couple seconds the pinkness will return. This does not happen in the damaged skin at this stage – it may have a darkly pigmented color.
Stage 2: There is an open, shallow ulcer with a red-pink color at the base of the wound. Sometimes there may be blisters present which are either intact or ruptured.
Stage 3: Structures beneath the skin such as fat may be exposed but at this stage, you should not see bone, tendons or muscle tissue.
Stage 4: Structures beneath this skin including bone, tendon and muscle may be seen in the bottom part of the ulcer
People at Risk: Some patients are more at risk than others of getting pressure sores.
1) Patients who cannot move very well because they have a medical problem. These people may sit or lay in one position for a long time. They need help to move to a different position so that the skin doesn’t form sores.
2) Older people are more prone to pressure sores because they often don’t move around as much and their skin is more fragile and thinner than a younger person.
3) Patients who have diabetes or nerve problems in their feet may not feel when a small pebble or area gets into their shoe or pressure pushes on the foot causing injury.
4) Patients in the hospital or nursing home are at especially high risk for many of the factors noted above – increased age, decreased mobility, and other complicated medical problems.
Prevention: Some things can be done to lower the chances of getting pressure sores
1) Repositioning the patient’s body every two hours so that they are not lying on one area where the skin is being crushed, pinched or pressure is building
2) Putting pillows between the ankles and knees to decrease the pressure on the skin over these boney areas
3) Raising the head of the bed when the patient is lying on their side to decrease the pressure on the hip bone
4) Getting special foam or soft mattresses that decrease the pressure on the areas of the body that have the most pressure on them
For patients in wheelchairs:
1) Use a special cushioned seat if possible to prevent pressure on the sacrum
2) Every hour tilt forward or to the side to release pressure on the seat
3) If ankles or heels press on the chair, use foam padding to protect against sores
4) Check skin regularly for signs of pressure or ulcers
Treatment: Pressure sores are treated differently depending on the stage of ulceration and how severe the damage to the skin is.
1) If there is mild erythema, the treatment is generally off-loading the area but decreasing the amount of time that this area is compressed by body re-positioning, and/or using pillows to cushion the area. We also use transparent films over the ulcers to protect the areas.
2) In patients who have diabetes, adequately managing blood sugars to keep them under good control is very important. Elevated blood sugars impede wound healing.
3) If there is dead or dying skin or soft tissues, this often needs to be removed to help prevent infection.
4) Special bandages may be needed to keep the healing tissue moist but prevent tissue maceration (from being too moist). Sometimes the dressings that we use to treat wounds can be very expensive.
5) Antibiotics may be prescribed if there is a wound infection
6) Medication for pain may also be prescribed
There are some tools to score the pressure and grade the healing process. These are helpful for patients who come back for repeat visits to wound care clinic or their primary care provider and there is a need to grade the healing by giving them a score. Some clinical features that are examined include:
1) Amount of Exudate
2) Skin color surrounding the wound
3) Peripheral tissue swelling
4) Peripheral tissue firmness around the wound
5) Amount of granulation (healing) tissue
6) How much epithilization is present
It’s important to optimize the nutritional status of patients with wounds. Particularly for patients who have Stage 3 and 4 ulcers, they need enough protein and calories to help heal these wounds.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO