Nursing Lecture | Staging And Nursing Methods Of Pressure Sores

December 29, 2022

About bedsore pressure sore care


Decubitus ulcers generally refer to pressure sores. Pressure sores, also known as pressure ulcers or decubitus ulcers, are due to long-term pressure on local tissues, resulting in continuous ischemia, hypoxia, malnutrition, tissue ulceration and necrosis. Skin pressure sores are a common problem in rehabilitation and nursing care.

Because decubitus patients are bedridden or paraplegic and hemiplegic, the superposition of primary disease and complications leads to prolonged wound healing cycle, and may even worsen repeatedly.




What are bedsores? How do bedsores form?


Traditional Decubitus Staging


1. Congestion and ruddy period (erythema period)


2. Inflammatory infiltration period (vesicle period)


3. Ulcer stage


4. Deep ulcer stage (cavity stage)


As the severity of the wound increases, the course of the disease also prolongs. If it’s not cared for properly, or if timely and effective treatment is not provided, the periosteum may eventually be injured, and a variety of serious infection diseases may occur.


1. Congestion and ruddy period (erythema period)


Due to the insufficient blood supply to the local skin, the lack of oxygen in the surrounding tissues, and the reactive expansion of the arterioles, the compressed part shows local congestion and the skin shows erythema. And the tolerance of the subcutaneous tissue is weaker than that of the epidermis. Although the skin is not broken at this time, the subcutaneous tissue and capillaries have been crushed.



Nursing points: Nursing care in the erythema stage should relieve the pressure in time to prevent the continuous deterioration and development of pressure sores. Take various preventive measures to make the decubitus part unsuppressed and avoid secondary pressure deterioration. For example, the pressure sore on the buttocks should be rested on the side, and a triangular pillow should be placed on the back to relieve the pressure. If the patient cannot lie on the side, Then put soft clothes on the front and back of the buttocks so that the wound does not directly contact the mattress.

While preventing pressure, attention should also be paid to the repair of pressure sore erythema. Use decubitus ointment that can penetrate subcutaneously. After the skin absorbs the ointment, it can repair the crushed subcutaneous tissue and capillaries from deep.


Inflammatory infiltration phase(vesicular phase)


Due to the damaged tissue compression, the inflammatory exudate cannot be discharged normally, resulting in congested blisters, accompanied by swelling of the subcutaneous tissue, and the skin color gradually darkens.





Nursing points: The skin should be protected during the vesicular phase , and decompression and anti-pressure measures should be strengthened. Small blisters can be repaired by directly applying decubitus ointment. For large blisters, use a sterile syringe to extract the liquid in it, apply decubitus ointment and then wrap it with gauze. .


Ulcer stage


Venous blood return is severely hindered, local congestion causes thrombosis, and tissue ischemia and hypoxia. In mild cases, the superficial tissue is infected, pus flows out, and ulcers form; in severe cases, the necrotic tissue turns black, and the purulent secretions increase and have a bad smell. Infection spreads to the surrounding and deep, reaching bones, and even causing sepsis.




Nursing points: In addition to the whole body and local nursing measures, debridement and anti-corrosion treatment and ointment muscle regeneration should be carried out to relieve wound pressure according to the wound condition, keep the wound clean, apply decubitus ointment to promote muscle growth, and use gauze to create a closed and humid healing environment is conducive to faster growth of granulation.


Deep ulceration phase (cavities, subcutaneous cavities, sinuses)


As the necrotic tissue is dug downward or around, the ulcer has entered the subcutaneous layer, and the depth can touch the muscle layer and bone surface, forming a cavity, subcutaneous cavity or sinus tract, accompanied by severe infection, and may even have a foul smell.




Nursing points: For pressure sores in this stage, the omissions and wrong methods in the previous nursing work should be corrected immediately, turn over and change positions frequently to avoid further pressure, and at the same time, immediately debride the wound and remove rot. In special cases, such as small sores with large cavity, or sinus tract pressure ulcers, need to be opened surgically to become an open wound, and then repaired with medicine.

At the stage of deep ulcer, you should also pay attention to systemic symptoms, such as fever, phlegm, pain, etc., which need to be actively dealt with and treated, and the course of this stage is relatively long, usually more than six months. It is necessary to patiently do nursing work such as turning over and changing positions, and nutritious meals.


Foam dressings are generally soft,

resilient, highly compliant, and non-adhesive to the wound.

Its most important role is to

absorbs exudate and maintains a moist healing environment,

It’s effective in promoting the healing of bedsores



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Huawei polyurethane foam dressing is a new type of dressing made of medical polyurethane material through the latest foaming process, mainly composed of three-layer structure. The front is a perforated silicone gel wound contact surface, the middle is a super absorbent foam layer, and the back is a waterproof and breathable PU film layer.


Moist healing: The three-layer structure provides dynamic exudate treatment and a moist wound healing environment, which promotes rapid wound healing.


Breathable and skin-friendly: the porous structure facilitates the conduction of exudate, has a large absorption capacity for liquid, and can absorb exudate.


Soft wound detection: the material is soft, comfortable, not sticky to hair, and does not damage the new epithelium and granulation. The wound contact layer can be uncovered to observe the wound and then reattach without losing viscosity.


Affordable: Polyurethane foam dressings can be used for up to 7 days, much higher than traditional wound dressings, and more cost-effective.


Painless dressing change: It is suitable for sensitive people, children, tumor patients and chronic non-healing wounds. The mild viscosity can reduce the wound damage and pain caused by it.


Freedom design: complete specifications, many styles, can be customized according to customer needs, providing more choices for clinical use.




1. Various acute and chronic wounds, especially wounds with a lot of exudate.


2. It can also be used to prevent and care for various pressure sores, diabetic feet, etc.


3. Moderate to high exudative wounds


4. Nursing care of wound and skin around intubation after tracheotomy (tracheotomy type)