Bed Sores in Nursing Homes

Bed sores (also called pressure sores, pressure ulcers, and decubitus ulcers) are areas of injured skin and tissue that often develop over the bony parts of the body, such as the tailbone, hip, ankle, or heel when small blood vessels are occluded by constant pressure and become damaged. They are a major problem in the elderly population. Approximately one in ten have at least one pressure sore. Pressure sores may be painful, take a long time to heal, and cause other complications such as skin and bone infections.

What are risk factors for the development of pressure sores?

  • Brain and spinal cord injury
  • Dementia
  • Drugs that cause sleepiness and confusion
  • Impaired mobility related to fractures, joint contractures, use of restraints, pain, stroke, and dementia
  • Swelling of the legs
  • Bowel and bladder incontinence
  • Malnutrition
  • Dehydration
  • Diabetes
  • Kidney disease
  • Heart failure
  • Vessel disease, especially in the legs
  • Cancer
  • Lung disease such as asthma
  • Depression
  • Certain medications (ex. steroids)
  • Obesity

Shear injuries can place residents at risk for pressure sores when deep tissue layers are forced in one direction while surface skin remains or is forced in the opposite direction when pulling a resident up in a bed or chair. They also are caused by placing the head of the resident’s bed up greater than a 30 degree angle for prolonged periods. Sacral (tailbone) pressure sores are often a result of shear injury.

Friction injuries can also increase the risk for pressure sores and are caused by sliding across a surface. Heel and elbows are often injured this way.

What positions cause pressure sores in specific body locations?

  1. Back – back of head, ear, back, elbow, tailbone, heels
  2. Side lying - ear, shoulder, ribs, hip, side of knee, foot, and ankle
  3. Stomach - ear, cheek, breast, genitalia, knees, toes
  4. Wheelchair - shoulder, tailbone, hip, back of knee, foot
  5. Sitting - tailbone, hip and buttocks, heels

What kind of treatments should I expect my loved one to receive if a pressure sore develops?

  • Keeping pressure sores moist with appropriate dressings and treatments.
  • Frequent monitoring of the pressure sore.
  • Proper turning and positioning - turning every two hours may not be often enough. Turning must be individualized to resident needs.
  • Keeping the resident off the pressure sore.
  • Using pillows to separate bony prominences when turning.
  • Not elevating the head of the bed more than 30-degrees for prolonged periods to prevent pressure on the buttocks.
  • Protecting pressure sores from infection.
  • Making sure that other medical problems are being addressed that may effect wound healing.
  • Maintaining adequate nutrition.
  • Controlling blood sugars if the resident is diabetic.
  • Keeping urine and stool out of pressure sores.
  • Controlling pain.
  • Using of pressure relief devices to the bed and chair.

Are all pressure sores preventable?

No, all pressure sores are not preventable, especially at the end of life. But, the majority that occur are preventable, and they happen too frequently due to inappropriate care and neglect. Some facilities put documentation in a resident’s chart stating pressure sores are unavoidable when in fact they are. In order to state that a pressure sore is truly unavoidable, nursing home staff must have performed a thorough assessment, developed a care plan unique for that person, with interventions that meet the minimum standard of nursing care. They must then show documentation in the chart that they followed each of these interventions and changed the care plan when interventions did not work. Most often times when a pressure sore developed, staff have not developed and implemented an appropriate plan of care.

Questions you can ask the nursing home about pressure sores:

  • How does the facility try to prevent pressure sores?
  • What percent of residents have pressure sores?
  • How many of these residents with pressure sores were admitted with the sores?
  • Does the facility have a wound care program, and how does it work?
  • How does the facility try to prevent pressure sores?

Resources

The American Health Care Association, Ongoing management
National Guideline Clearinghouse