Pressure Sores

Symptoms

Pressure sores usually develop on the skin over a bony area where there is less cushion between the skin and bones. About 95% of pressure sores develop on the lower part of the body, on the skin over the sacrum and tailbone (the lowest part of the back), the hips, buttocks, or heels.⁵ Pressure sores also occur on the back of the head, the backs of ears, around the shoulders and elbows, between the knees, and over the ankles.

Pressure sores are described in four stages:⁶

• Stage 1 sores are not open wounds. The skin is closed and may be painful. The skin may appear reddened or darker than normal, like a bruise, and there are no breaks or tears in the skin. Skin temperature is often warmer, but can be cooler than the skin around it. And the stage 1 sore can feel either firmer or softer than the surrounding skin.
• At stage 2, the skin usually breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion) or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
• During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
• At stage 4, the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.

In stages 3 and 4 there may be little or no pain due to significant tissue damage. Serious complications, such as infection of the bone (osteomyelitis) or blood (sepsis), can occur if pressure sores progress.

Sometimes a pressure sore does not fit into one of these stages.⁶

• In some cases, a deep pressure sore is suspected, but cannot be confirmed. The area of skin may look purple or dark red, or have a blood-filled blister. If you or your doctor suspect a pressure sore, the area is treated as though a pressure sore has formed.
• There are also pressure sores that are "unstageable," meaning that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the sore to determine the stage.

Conditions that have symptoms similar to pressure sores include:⁵

• Tissue death from other causes (gangrene).
• Skin sores due to other conditions, such as venous insufficiency, peripheral arterial disease (PAD), diabetes, or injury.
• Skin cancer, which may cause sores similar in appearance to pressure sores.

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Author:	Shannon Erstad, MBA/MPH	Last Updated: March 15, 2007
Medical Review:	Martin Gabica, MD - Family Medicine Margaret Doucette, DO - Physical Medicine and Rehabilitation, Wound Care, Hyperbaric Medicine
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