Pressure sore also known as bed sore and decubitus ulcer. A pressure sore is a localized ulceration of tissue. Bed sore occurs due to necrosis of tissue, because of prolonged pressure over the area. Long-time pressure causes a decreased blood supply in particular sites and damages pressure sites or causes ischemia on necrosis. Moisture is a favorable condition for the growth of the microorganism.

Common site of Pressure ulcer

• In supine position – occipital, scapula, sacral region, elbow, heel.
• In side-lying position – Greater trochanter, ribs, ear, cheeks, acromion process, malleolus of ankle joint.
• In prone position – Ear, cheeks, ribs, breast in female, male genitalia, toes and knee.

Cause of Pressure Sore (Bed Sore)

• Pressure (primary cause of pressure ulcer).
• Moisture (favourable cause of pressure ulcer).
• Friction (rough and hand surface cause tissue damage).
• Shear (opposite force on sacrum during sitting position).
• Presence of pathogenic organisms.

Risk factors of Pressure Sore (Bed Sore)

• Bedridden patients.
• Unconscious and coma patient.
• Obese patient.
• Diabetic patient.
• Paralysis patient.
• Edema
• Surgical client with limited movement.
• Incontinence of urine and stool.
• Agitated client in restraints.
• Malnourished patient.
• Burn patient.
• Impaired circulation.
• Complete bed rest.
• Oedematous patients.
• Emancipated patient.
• Spinal cord injury.

Symptom of bedsore

Stage – 1  bedsore

• Skin redness
• Pain
• Skin warm, cool, firm, or soft
• Epidermis layer of skin involved.

Stage – 2 bedsore

• Blister formation
• Open sore
• Dermis layer involve
• Pain
• Bluish discoloration around the site
• Red and irritated skin.

Stage – 3 bedsore

• Subcutaneous tissue involve
• Pain absence
• Watery discharge from the blister
• Brown color around the skin
• Skin tissue damage
• Develop an open, sunken hole.

Stage – 4 bedsore

• Wounds affect all layers of skin muscles etc.
• Bone and tendons are visible.
• Damage muscles, bone,s and joints.
• Pain absence.
• Pus formation.
• Purple, black color skin around the wound.

Diagnosis of bedsore

• Braden scale was used to evaluate the risk of pressure ulcers in clinical practice.
• Braden scale is developed by Nancy Braden and Barbara Bergstrom.
• Pressure ulcer findings according to Braden score are

18 – 23 points – no risk

15 – 18 points – mild pressure sore

13 – 14 points – moderate pressure sore

10 – 12 points – severe pressure sore

Less than 10 points – very severe pressure sore

Nursing Management of Bedsore

• Apply the 1% zinc oxide powder.
• Provide warm applications to the site.
• Apply heat for the healing of the wound – a 100-watt bulb for 10 minutes.
• Use Normal saline to clean the site.
• Use a few drops of insulin for the healing of wounds.
• Expose the site in the air to dry.
• Direct oxygen is administered at site by catheter to heal wounds.
• Apply the waterproof cream and ointment.
• Antibiotics administered.

Prevention of pressure sore

• Identify the risk factors that are prone to the development of bed sore.
• Remove the cause of bedsores.
• Bedridden clients conduct very little movement in bed.
• Assess the patient for moisture, redness, and blister and skin discoloration.
• Keep the client clean and dry.
• Change the patient’s position every 2 hours.
• The patient skin is well lubricated by using powder.
• Prevent the incontinence of urine and faces.
• Provide adequate food and fluids.
• Provide water matters for burn patients.
• Provide a smooth and wrinkle free bed.
• Stimulate the body circulation.
• Avoid the scratching on the skin.
• To avoid pressure ulcers, use comfort devices.
• Educate about maintaining personal hygiene.
• Encourage the client to move in bed.
• Avoid vigorous massages at pressure sites.
• Administer high-calorie and high-protein diet with excessive fluid intake.
• Provide health education.