Pressure Ulcer (Bedsore)

What Is a Pressure Ulcer?

A pressure ulcer is localized tissue damage that develops at bony prominences due to prolonged pressure, friction, or shear forces. In these areas:

• Blood flow to the skin and underlying tissues decreases
• Cells become deprived of oxygen
• Tissue death (necrosis) begins
• Open wounds and ulcers form

A pressure ulcer is not just a skin problem but a medical issue that can significantly affect the patient's overall health status.

Where Do Pressure Ulcers Occur?

Pressure ulcers most commonly develop where bony prominences are close to the skin:

In Patients Lying on Their Back

• Coccyx (tailbone/sacrum)
• Heels
• Back of the shoulders
• Back of the head (occiput)
• Shoulder blades
• Elbows

In Patients Lying on Their Side

• Side of the hip (greater trochanter)
• Inner and outer knee surfaces
• Ankles
• Shoulders
• Ears

In Patients Lying Face Down

• Face (especially cheeks and forehead)
• Front of the knees
• Chest and abdomen
• Toes

In Seated Patients (Wheelchair)

• Ischial prominences (sit bones)
• Coccyx
• Heels
• Shoulder blades

Stages of Pressure Ulcers

Pressure ulcers are classified into four stages based on the depth of tissue damage:

Stage 1: Non-Blanchable Redness

• Skin is intact but red
• Does not turn pale when pressure is applied
• Pain, itching, or burning sensation may occur
• Temperature changes may be observed
• Reversible with early intervention

Stage 2: Partial Thickness Loss

• Superficial loss of epidermis and/or dermis
• Shallow open wound or blister
• Pink-red, moist wound base
• Tender and painful

Stage 3: Full Thickness Tissue Loss

• Subcutaneous fat tissue is visible
• Muscle, tendon, and bone are not yet visible
• Crater-like wound appearance
• May contain dead tissue (slough)
• Tunneling and undermining may occur around the wound

Stage 4: Full Thickness Tissue Loss (Deep Structures)

• Muscle, tendon, bone, or supporting structures visible
• Wide and deep wound
• Significant dead tissue and eschar
• Serious infection risk
• Requires surgical treatment

Unstageable Ulcer

The wound base is completely covered with dead tissue or eschar, making depth assessment impossible. Staging cannot be done until dead tissue is removed.

Deep Tissue Injury

Skin appears intact but with purple or maroon discoloration; indicates damage to underlying tissue. Can rapidly progress to stage 3 or 4.

Risk Factors

Factors that predispose to pressure ulcer development:

Mobility-Related Factors

• Bedridden or wheelchair-bound status
• Decreased level of consciousness (coma, advanced dementia)
• Paralysis (stroke, spinal cord injuries)
• Severe muscle weakness
• Pain or restrictive medical conditions

Nutrition and Hydration Status

• Inadequate protein intake
• Vitamin and mineral deficiencies (especially C and zinc)
• Dehydration
• Weight loss or severe obesity

Medical Conditions

• Diabetes
• Vascular diseases (peripheral arterial disease)
• Anemia
• Respiratory diseases (reduce oxygenation)
• Weakened immune system
• Kidney failure

Skin Condition

• Dry and sensitive skin
• Excessive moisture (incontinence, sweating)
• Thinned skin (aging)
• Previous pressure ulcer history

Environmental Factors

• Hard mattress or chair surface
• Wrinkled sheets
• Inadequate position changes
• Friction and shear forces

Symptoms of Pressure Ulcers

Symptoms to watch for early diagnosis:

• Changes in skin color (redness, bruising)
• Changes in skin temperature
• Hardening or softening
• Swelling or edema
• Pain or tenderness
• Open wound or blister
• Discharge or foul odor (in advanced stages)
• Fever (sign of infection)

Diagnosis

Clinical Evaluation

Pressure ulcer diagnosis is usually made through careful examination:

• Location of the wound
• Wound diameter and depth
• Appearance of the wound base
• Condition of surrounding tissue
• Characteristics of discharge
• Accompanying signs of infection

Additional Evaluations

• Blood tests (CRP, blood count, albumin, prealbumin)
• Wound culture (if infection is suspected)
• Imaging methods (MRI, CT): In cases of deep tissue involvement and bone infection (osteomyelitis) suspicion

Pressure Ulcer Treatment

Treatment is planned based on the wound's stage, location, and the patient's general condition.

Pressure Reduction

In all stages, the fundamental principle is to reduce pressure on the affected area:

• Regular position changes: Every 2 hours
• Pressure-reducing mattresses and cushions: Air, gel, foam-supported
• Correct positioning techniques
• Support of bony prominences: With pillows
• Head of bed should be kept below 30 degrees (reduces shear force)

Wound Care

Wound care is planned according to the characteristics of each stage:

Stage 1

• No pressure on the area
• Skin should be kept clean and dry
• Application of moisturizer
• Transparent film dressings may be used

Stage 2

• Wound is gently cleaned (normal saline)
• Moist wound healing is provided
• Hydrocolloid, foam, or alginate dressings
• Regular dressing changes

Stages 3 and 4

• Dead tissue is removed (debridement)
• Wound cleaning is performed meticulously
• Special wound dressings are used
• Infection control
• Nutritional support
• Surgery may be required

Debridement (Removal of Dead Tissue)

Dead tissue prevents healing and creates infection risk. Cleaning methods:

• Surgical debridement: Mechanical cleaning with scalpel (fastest)
• Autolytic debridement: With the help of wound dressings
• Enzymatic debridement: Ointments containing special enzymes
• Mechanical debridement: During dressing changes
• Biological debridement: Sterile larvae (in special cases)

Infection Control

In infected wounds:

• Wound culture is taken
• Systemic or local antibiotic therapy
• Emphasis is placed on wound cleaning
• Abscess drainage may be required

Surgical Treatment

In stage 3 and 4 wounds, when conservative treatment is unsuccessful, surgical treatment may be required:

• Flap surgery: Closure of the wound with nearby tissue
• Graft procedures: Skin transfer
• Ostectomy: Correction of affected bony prominences
• Negative pressure wound therapy (VAC): Accelerates wound healing

Nutritional Support

Adequate nutrition is essential for wound healing:

• High-protein diet (1.2-1.5 g/kg per day)
• Adequate calorie intake
• Vitamin C, A, zinc supplementation
• Adequate fluid intake
• Dietitian follow-up

Prevention of Pressure Ulcers

Pressure ulcers are largely preventable. Prevention strategies:

Risk Assessment

• Regular skin examination (at least once a day)
• Risk assessment tools such as the Braden Scale
• Intensive care plan in high-risk patients

Position Changes

• Position change every 2 hours
• 30-degree lateral position
• Keeping heels off the bed
• Not keeping the head of the bed too high

Skin Care

• Keeping the skin clean and dry
• Gentle cleaning (avoiding irritating soaps)
• Regular moisturizing
• Quick cleaning in cases of incontinence
• Avoiding excessive dryness

Choosing the Right Surface

• Pressure-reducing mattresses
• Wheelchair cushions
• Heel protectors
• Supporting bony prominences

Nutrition

• Adequate protein and calories
• Ensuring hydration
• Vitamin and mineral supplements

Mobilization

• Getting up as early as possible
• Passive and active exercises
• Physiotherapy support

Complications

Complications that may occur in untreated or late-intervened pressure ulcers:

• Local and systemic infection (cellulitis, sepsis)
• Bone infection (osteomyelitis)
• Joint infection (septic arthritis)
• Anemia and protein loss
• Scar tissue and contractures
• Marjolin's ulcer (skin cancer development in long-standing wounds)
• Significant decrease in quality of life
• Prolonged hospital stay