Bed sores !!!!

Pressure ulcersInjury to skin and underlying tissues , from prolonged pressure to areas mostly bony areas ex heels sacrum
Stage 1 redness that doesn’t blanch when touched, in darker skin tones discoloration is noted and also doesn’t blanch when touched.painful when touched could be firm ,soft ,cool when compared to surrounding areas
Stage I I

The skin and underlying tissue is damaged. Could appear as a fluid filled blister or could have ruptured 
Stage i i i 
Deep wound

Crater looking 

Loss of tissue fat may be exposed
Stage iv 
Large scale loss of tissue

May show bone tendon or muscles

Bottom of wound most likely contains dead tissue which appears yellow or dark

The wound is covered with yellow,brown or black dead tissue 

Which makes it impossible to evaluate how deep the wound is
Deep tissue injury 

May look purple ,maroon,be soft cool 

Friction,shearing,sustained pressure 
Risk factors 


Lack of sensory perception 

Poor nutrition/hydration 

Excess moisture or dryness


Bowel bladder incontinence



None or joint infection 

Treatment include determine size depth and stage

Check for fluid and debris in wound that can indicate severe infection 

Sent tissue culture to test for fungal or bacterial infection 
Treatment requires a multidisciplinary approach 

A primary md to oversee care

A physical therapist to increase mobility 

A dietitian to help improve nutritional status

It’s step is decreasing pressure 

Repositioning frequently 


Bound q15 min shifts 


Cleaning wound to prevent infection 

Applying dressing to protect and promote healing

Debridement may be necessary to remove dead tissue so healing can occur

Types are


Autolytic uses special dressing to keep wound mount and clean
Enzymatic apply dressing and enzymes to break down dead tissue 
Mechanical Debridement

Looses and remove debris this may be done with pressurized irrigation device 
Also think about pain management and abx therapy

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