Learn About Bed Sore Prevention Strategies

Understanding Pressure Injuries and How They Form

Bed sores, medically known as pressure injuries or pressure ulcers, are areas of damaged skin and tissue caused by prolonged pressure against the skin. They typically develop on bony parts of the body where skin is stretched tightly over bone with little cushioning. Common locations include the tailbone, heels, hips, shoulders, and the back of the head. According to the National Pressure Injury Advisory Panel, pressure injuries affect approximately 2.5 million patients in acute care settings and 1.3 to 3 million in long-term care facilities each year.

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The development process happens in stages. When pressure is applied continuously to an area of skin, it reduces blood flow to that region. Blood carries oxygen and nutrients that keep tissue healthy. Without adequate blood flow, skin cells begin to break down. A pressure injury can develop in as little as 2 to 3 hours in some vulnerable individuals, though this timeline varies based on factors like age, nutrition, moisture, and overall health. The process occurs in layers—it starts at the deepest tissue layers and works outward, which means visible damage on the skin's surface often indicates more extensive damage underneath.

Several risk factors increase the likelihood of developing pressure injuries. Immobility is the primary risk—people who cannot move around frequently or reposition themselves are at highest risk. Other significant factors include advanced age, poor nutrition, incontinence, low body weight, diabetes, and conditions affecting blood circulation. Friction and shearing forces, which occur when skin is dragged across surfaces or when the body slides down in a bed or chair, compound the risk by damaging skin layers.

Practical takeaway: Understanding how pressure injuries form helps explain why prevention strategies focus on movement, repositioning, and reducing friction. Recognizing risk factors in yourself or a care recipient allows for targeted prevention efforts before damage occurs.

The Importance of Regular Position Changes and Movement

Regular repositioning is considered the most effective single strategy for preventing bed sores. The principle is straightforward: changing position relieves pressure from one area of the body and redistributes it elsewhere. Medical guidelines recommend repositioning every 2 hours for individuals confined to bed, though some sources suggest more frequent changes for those at very high risk. This timeframe is based on research showing that pressure-related tissue damage accelerates significantly after 2 hours of continuous pressure in vulnerable populations.

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The specific repositioning schedule should consider the individual's condition and risk level. A common approach involves rotating between different positions: back, left side, right side, and prone (face down) if tolerated. When lying on the back, a pillow under the head prevents pressure on the back of the skull, while pillows under the calves lift heels completely off the mattress—a critical point since heels are especially prone to pressure injuries. When side-lying, placing a pillow between the knees prevents the knees and ankles from pressing directly against each other, and a pillow behind the back prevents rolling onto the sacrum (tailbone).

For individuals in wheelchairs or sitting positions, pressure relief is equally important. Those who can perform independent movement should shift their weight every 15 to 20 minutes. A simple weight-shift involves leaning to one side, then the other, or leaning forward. For those unable to move independently, caregivers should assist with position changes at least every hour while seated. Some specialized wheelchairs and cushions include features that redistribute pressure, but these are supplements to regular movement, not replacements for it.

Movement extends beyond repositioning in bed or chair. Individuals with mobility should be encouraged to walk, stand, or engage in other activities as their health permits. Passive range-of-motion exercises, where a caregiver gently moves a person's joints, can help maintain circulation even when the individual cannot move independently. Research from the American Geriatrics Society indicates that individuals who maintain any level of physical activity have significantly lower rates of pressure injuries compared to those who remain completely sedentary.

Practical takeaway: Create a repositioning schedule and document it. Using a chart or log helps ensure consistency and allows caregivers to coordinate efforts. Set phone reminders or use care scheduling apps to maintain the 2-hour repositioning interval for bed-bound individuals.

Choosing Appropriate Support Surfaces and Bedding

The surface a person lies or sits on significantly impacts pressure injury risk. Traditional firm mattresses can actually concentrate pressure on bony areas, making them unsuitable for individuals at risk. Various specialized mattresses and cushions are designed to distribute pressure more evenly across larger surface areas, reducing the peak pressure on vulnerable zones. These support surfaces fall into several categories, each with different mechanisms and appropriate uses.

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Foam mattresses and overlays are among the most common and affordable options. These are made from viscoelastic foam or polyurethane foam that softens in response to body heat, conforming to the body's shape. Standard foam overlays are typically 2 to 3 inches thick and are placed over an existing mattress. More advanced foam mattresses replace the entire bed surface. Research published in the Cochrane Database of Systematic Reviews found that high-specification foam mattresses reduced the incidence of pressure injuries compared to standard hospital mattresses in hospital settings.

Alternating pressure mattresses use air chambers that inflate and deflate in a timed sequence, regularly shifting pressure from one area to another. These mattresses are particularly valuable for individuals at very high risk or those who already have early-stage pressure injuries. Some models alternate pressure every 5 to 10 minutes. Water beds and gel mattresses work through similar principles of distributing body weight across a larger surface area with different materials. Low-air-loss mattresses use air to create a cushion between the body and the surface while also managing moisture, which addresses two prevention needs simultaneously.

Selecting the right support surface involves considering the individual's mobility level, risk factors, body weight, and budget. Someone with limited mobility and multiple risk factors may benefit from an alternating pressure system, while someone with moderate risk might do well with a high-quality foam mattress. Healthcare providers or wound care specialists can assess specific needs and recommend appropriate options. It is important to note that no mattress or cushion eliminates the need for repositioning; these surfaces reduce pressure but do not replace the fundamental strategy of changing position regularly.

Beyond mattresses, regular sheet changes, keeping bedding dry, and using moisture-wicking materials help prevent skin breakdown. Moisture from sweat or incontinence weakens skin integrity, making it more vulnerable to damage. Protective pads and absorbent briefs should be changed promptly when soiled, and skin should be gently cleaned and dried.

Practical takeaway: Evaluate current sleeping and sitting surfaces honestly. If someone is at risk and remains on a standard mattress, exploring options for a pressure-reducing surface is a concrete step toward prevention. Request a professional assessment if uncertain about which type would be most beneficial.

Skin Care, Nutrition, and Moisture Management

The condition of the skin itself directly affects vulnerability to pressure injuries. Healthy skin with good blood circulation and proper moisture balance is far more resistant to breakdown. A foundational skin care routine for those at risk includes gentle daily cleansing, thorough drying, and regular inspection. Skin should be washed with mild soap and lukewarm water, then dried completely, paying special attention to skin folds and areas that tend to remain moist. Lotion applied to dry areas helps maintain skin elasticity, though areas prone to pressure should be kept dry rather than constantly moisturized.

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Incontinence presents a particular challenge because urine and feces contain bacteria and enzymes that break down skin. Individuals with incontinence should have skin cleaned promptly after soiling, dried thoroughly, and protected with barrier creams or ointments that create a water-resistant layer. Absorbent pads should be changed frequently rather than left in place for extended periods. Some facilities use specialized skin cleansing products designed specifically for incontinent individuals that are gentler than standard soap.

Nutrition plays a surprisingly powerful role in pressure injury prevention. The skin and underlying tissues require adequate protein for repair and maintenance. Albumin, a blood protein that reflects nutritional status, is a strong predictor of pressure injury risk. Studies have shown that individuals with low albumin levels develop pressure injuries at significantly higher rates. A diet adequate in protein, calories, vitamins (particularly vitamins C and A), and minerals (zinc and iron) supports skin health and healing. The National Pressure Injury Advisory Panel recommends ensuring adequate caloric and protein intake for those at risk, though specific recommendations should be tailored to individual health conditions.

Hydration status also