Why Bedsores Happen

Imagine someone who regularly sits in a wheelchair or stays in bed for hours. They can’t adjust their position. No one helps them move. Their skin and certain tissues are trapped between the wheelchair or bed and the bone. Over time, this prolonged pressure slowly cuts off blood flow to these vulnerable areas, starving them of oxygen and other nutrients. The skin—especially the skin covering bony areas like the heels, ankles, hips, and spine—breaks down. The tissue beneath can weaken and die.

And that pressure is only one factor. The Mayo Clinic has identified other forces that act on a patient’s skin and make them more vulnerable to bedsores.

Friction is created when a patient is being moved or their clothing changed, and their skin drags. , This makes skin that is already delicate even more vulnerable to breaking down. And the friction is more severe if the skin is most—a common risk among patients who cannot fully control their bladders.

Another danger is shear—which is what the patient feels when a surface is moving in one direction, but their skin is sliding the opposite way. Imagine that while your hospital bed is being raised, your body slides downward. The bed is moving one way. Your skeleton is moving the opposite way. But your skin? It’s caught in the middle, getting pulled and stretched.

Age is also a significant risk factor for bedsores. Most develop in people over the age of 70. This happens for several reasons. Older adults tend to have thinner skin, which is easier to damage. They are also more susceptible to being malnourished due to prolonged illnesses or other causes, which leads to less cushioning between skin and bone. And, according to the Mayo Clinic, bedsores are a particular hazard for people with medical conditions that limit their ability to move—which are common in old age.

This is why nursing home residents get more bedsores than any other population—and get twice as many as hospital patients. But while nursing home residents suffer the greatest risk, the facilities are least equipped to fight this problem. This is because nursing homes have fewer people on staff, and each staff member is responsible for more patients. And the staff members they have aren’t always trained well enough to catch a bedsore before it becomes a hazard—or to take the steps necessary to prevent one:

Reposition: Was the resident turned or repositioned at least every two hours while in bed or every fifteen minutes while in a wheelchair?

Relieve: Was the resident given pillows or other devices to relieve pressure wherever there isn’t much natural padding between skin and bone? And if a stage 1 or stage 2 bedsore developed, was the patient given a pressure-reducing mattress to help arrest it?

Inspect: Was the resident’s skin checked every day for signs of bedsores? Were steps taken to protect the skin from becoming too moist or too dry, as both can increase friction?

Nourish: Was the resident properly hydrated and given a diet rich in protein and nutrients so they could fight infection and bodily breakdown?

Clean: Was the resident bathed often? Was their skin always free of urine and
feces that cause it to deteriorate? If not, bacterial infection from fecal matter can cause serious infections at the site as well as life-threatening conditions throughout the body, including sepsis.

Alert: Did staff members caring for the resident report signs of infection or alert a doctor when a bedsore first became apparent or as it continued to develop?

The process for treating a bedsore can be long, difficult, and expensive. In fact, caring for just one deep-tissue bedsore can cost over $70,000. And even after bedsores heal, skin and other tissue have already been damaged or destroyed—which means healing is never perfect.

Even more unsettling, bedsores can appear—and progress—in very little time.

How They Deepen

As a bedsore worsens, it progresses from one stage to another to another… The National Pressure Ulcer Advisory Board has defined the stages based on the devastation the skin has suffered.

Stage I:

The skin is not broken, but may be red or discolored. Compared to skin surrounding the site, the affected area may feel warmer or cooler, more firm or more mushy, or may be more painful or itchy.

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Stage II:

The ulcer now looks like an abrasion or a blister that is either filled with fluid or that has already ruptured. The outer layer of skin has lost some of its thickness, and the underlying layer may also be damaged. To some, the wound may seem superficial, but the bedsore has already advanced significantly—which is why caregivers must be vigilant in their monitoring.

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Stage III:

The tissue underneath the skin may be damaged or dead all the way down to the connective tissue. At the bottom of the wound, you may see some yellowish, dead tissue. At the surface, the wound looks like a deep crater, blackening at the edges. At this stage, the bedsore has become much harder to treat.

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Stage IV:

The wound is now deep and open, revealing tissue death and destruction to muscle, bone, and supporting structures like tendons and joints—some of it massive. You will see exposed bone and connective tissue. You will also see yellow or dark, crusty tissue at the bottom of the wound.

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“Unstageable:”

Sometimes, the surface of a pressure ulcer will be covered with yellow, brown, black, or dead tissue. In these cases, it may not even be possible to see how deep the destruction to skin and tissue goes.

What Happens Next

Bedsores can lead patients to suffer from a host of complications. One of the most serious is sepsis. This occurs when bacteria enter the body through damaged skin and use the bloodstream to move throughout the body, seeding it with infection. Sepsis is a fast-moving, ravaging condition that can cause organ failure and death.

Other infections can also develop, including some that burrow into joints and bones and force the amputation of a limb. One infection that may occur is necrotizing fasciitis, which destroys the tissue that surround our muscles. It can cause death in as little as 12 to 24 hours.

Myonecrosis is yet another risk, a rare form of gangrene that destroys muscle tissue itself and in some cases, leads to death. The onset of this infection can be so rapid, tissue changes are apparent within minutes.

And in chronic wounds that won’t heal, cancer may develop. Treating this aggressive carcinoma often requires surgery—but in many cases, it has spread to the lymph nodes before it is even diagnosed.