Bed Sores - Decubitus Ulcers

Gregory J. Jansen

One of the most common, and most preventable, injuries that people suffer in nursing homes is decubitus ulcers, also known as bed sores or pressure sores. Decubitus ulcers are very painful and can be life threatening. Proper care by the nursing home staff can virtually eliminate the occurrence of decubitus ulcers, which generally includes repositioning bedridden residents every two hours per accepted nursing procedures. However, many nursing homes are understaffed, and residents are left for hours, days, even weeks in the same position. Decubitus ulcers are invariably the result.


The most frequently cited cause of decubitus ulcers is constant pressure on the skin. As a result of the constant pressure, blood blow is cut off to the skin and it starts to deteriorate, eventually becoming necrotic.

Other factors that often contribute to this problem are:

  • Moisture - wetness from perspiration, urine or feces increases the skin's vulnerability. Therefore, residents suffering from incontinence are at an increased risk of developing decubitus ulcers.
  • Shearing and Friction - Rubbing of the skin causes irritation which increases the skin's vulnerability. One important cause of shearing is when the nursing staff drags a resident across the bed rather than lifting him, which tends to cause friction and irritation to elbows and heels. Also, raising the head to the bed more than 30 degrees increases the shearing forces at the buttocks, tail bone and low back, the other frequent site of decubitus ulcers.
  • Poor Nutrition - Decubitus ulcers are more likely in residents that suffer from malnutrition, especially deficiencies of albumin (a protein), Vitamin C, Vitamin E, calcium and zinc. Anemia is also associated with an increase risk of developing decubitus ulcers.
  • Circulatory Problems - People with circulatory problems already have problems with blood circulation, and therefore are more susceptible to skin breakdowns such as decubitus ulcers. Thus, people with artherosclerosis or diabetes are at increased risk.
  • Decreased Movement - Clearly, people who are unable to move without assistance are at the greatest risk of developing decubitus ulcers. It does not matter if the decreased movement is a result of a long term condition or a temporary injury which will heal - the lack of movement allows for pressure to stay fixed on one place on the skin, cutting off the blood. Residents who can shift their weight or turn on their own are at decreased risk.
  • Decreased Sensation - The inability to feel an injury reduces the chance that it will be caught and treated in the early stages. Therefore, people with diabetes or spinal injuries that diminish the resident's ability to feel different parts of the body are at greater risk, as they may be injured without knowing it.
  • Age - As we get older, our skin gets thinner, making us more susceptible to skin breakdowns like decubitus ulcers.


There are four stages of decubitus ulcers, the higher the stage the more serious the wound.

STAGE I: The skin is reddened, unbroken, and may be slightly warm to the touch. This is a superficial wound which quickly fades when pressure is removed. A Stage I decubitus ulcer is a warning sign, and should be a signal for further intervention, including repositioning more frequently, cushioning, and improved nutrition.

STAGE II: The skin at this stage looks like a blister, either broken or unbroken. This wound is no longer superficial as a partial layer of skin has been injured. The treatment at this point focuses on keeping the area clean, covered and protected, in addition to repositioning, cushioning and improved nutrition.

STAGE III: The wound now extends throughout all layers of the skin and is a primary site for infection. This type of wound requires immediate medical care to promote healing and prevent infection. Left on its own, a Stage II decubitus ulcer will progress very rapidly.

STAGE IV: This is the worst stage of decubitus ulcer. The wound now extends not only throughout the skin, but into muscle tissue as well. This type of wound requires treatment by a medical professional skilled in wound care. Often surgery is required to debride necrotic tissue. Amputation is necessary is some situations. The risk of infection is very high and can be life threatening.


It is the job of the nursing staff at the nursing home to prevent decubitus ulcers in residents, but clearly that does not always happen. There are things, however, that loved ones can do to help prevent decubitus ulcers in a nursing home resident.

The primary thing we can do is to check the resident's skin. If the resident is always covered by a sheet or blankets, check the resident's body for signs of skin breakdown, especially at the elbows, heels, hips, buttocks and low back/tailbone. Look for redness, blisters, breaks in the skin, abrasions and rashes. Bony areas are most susceptible. If you find any of these conditions, report it to the nursing staff immediately.

The nursing staff or physician can usually diagnose a decubitus ulcer by simply examining the resident's skin. Further diagnostic tests are usually unnecessary unless the wound is infected. If the wound is infected, blood tests, cultures and x-rays may be required to determine if sepsis or osteomyelitis have developed.


In addition to being painful wounds, decubitus ulcers can and often do lead to infections that can be painful and debilitating, in addition to being life threatening. Infection may develop in the skin (cellulitis), in deeper tissue and muscle, in the bone (osteomyelitis), in the blood (sepsis), in the joints (septic arthritis), the lining of the heart (endocarditis) and the fluids of the brain and spinal cord (meningitis). These are all serious, life threatening conditions, which is why decubitus ulcers need to be taken so seriously. Typically, the resident does not die of the decubitus ulcers but rather the infections that develop from the wound.

Sepsis is probably the most common infection that develops from decubitus ulcers, and is a very serious illness. Sepsis is the 11th leading cause of death overall, and there are over 750,000 cases of sepsis every year in the United States, accounting for 215,000 deaths. Many of these cases arise in nursing homes, which report a high incidence of sepsis arising from decubitus ulcers.