A bedsore, or pressure injury, is an area of localized damage to the skin and underlying tissue that usually develops over a bony prominence. These injuries are a serious health concern, capable of leading to severe infection, prolonged hospitalization, and a significant decline in a resident’s quality of life. In a supervised care setting like a nursing home, pressure injuries are widely regarded as largely preventable adverse events. Their development results from a complex interaction between external mechanical forces, the resident’s internal physiological vulnerability, and the quality of institutional care provided.
The Mechanics of Pressure Injury Formation
The fundamental cause of a pressure injury is sustained pressure applied to a specific area of the body, such as the tailbone, hips, heels, or shoulder blades. When soft tissue is compressed between a bony prominence and an external surface, the constant force is greater than the pressure inside the capillaries. This sustained compression obstructs blood flow, leading to a condition called ischemia, which deprives the tissue of the oxygen and nutrients necessary for survival.
Tissues can tolerate high pressure for short periods or low pressure for longer periods, but when the pressure is unrelieved, the cells begin to die, leading to inflammation and tissue breakdown. Muscle tissue, which has a higher metabolic demand, is often damaged earlier and deeper than the skin’s surface. This explains why a small area of surface redness can sometimes indicate a larger injury beneath the skin.
Two other mechanical forces, shear and friction, intensify the damaging effects of pressure. Friction occurs when the skin rubs against a rough surface, like a sheet, wearing away the skin and making the tissue susceptible to abrasion. Shear occurs when the skin remains stationary while the underlying bone and muscle shift, such as when a resident slides down in a bed or chair. This internal sliding stretches and tears the deep blood vessels that bridge the muscle and fascia, causing immediate and extensive damage to the tissue’s microcirculation.
Resident Vulnerability and Internal Risk Factors
Beyond the physical mechanics, a nursing home resident’s internal health status is a major determinant of their susceptibility to skin breakdown. One of the primary internal factors is poor nutritional and hydration status, which compromises the skin’s ability to resist injury and repair itself. Protein is required for maintaining skin integrity, supporting the immune system, and rebuilding damaged tissue.
Protein deficits slow the wound healing cascade and decrease the tensile strength of the skin. Dehydration causes skin tissue to lose its natural plumpness, reducing the cushioning around bony areas and increasing susceptibility to friction damage. Insufficient fluid intake also impairs the body’s ability to transport vital nutrients to the periphery, further hindering tissue health.
Pre-existing medical conditions also increase vulnerability by limiting the body’s defenses. Conditions like diabetes or peripheral vascular disease impair circulation, reducing blood flow and making the tissue more prone to ischemia and slower to heal once injured. Furthermore, residents with impaired sensory perception, often due to neurological conditions, cannot sense the discomfort or pain that would normally prompt an unconscious shift in position.
Incontinence is another serious risk because prolonged exposure to urine and feces leads to skin maceration. Maceration, the softening and breakdown of skin caused by continuous moisture, makes the tissue fragile and easily damaged by friction or pressure. The resulting irritation, known as incontinence-associated dermatitis, compromises the skin barrier and provides an entry point for bacteria, accelerating the ulcerative process.
Institutional Care Deficiencies and Neglect
In a nursing home setting, the conversion of physiological risk into a pressure injury often points to systemic care deficiencies. The failure to relieve pressure in a timely and consistent manner is the core deficiency. For immobile residents, the medically recommended standard is to reposition the patient at least every two hours to restore blood flow to compressed areas.
When staffing levels are low, this frequent repositioning schedule is often missed or delayed, leaving residents in the same position for extended durations. Lower hours of direct care provided by registered nurses and certified nursing assistants are associated with higher rates of pressure ulcer development. A decrease in staff levels or a change in the staffing mix can directly correlate with an increase in adverse outcomes.
Effective prevention requires the proper use of risk assessment tools upon admission and throughout the resident’s stay. The Braden Scale is a widely used tool that systematically evaluates six factors to determine a resident’s specific risk level:
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
Failing to conduct this assessment, or failing to implement the targeted preventative measures indicated by a low score, constitutes a lapse in care.
Poor communication and documentation further contribute to the problem by creating gaps in the care plan. If a nurse fails to document the stage of an existing injury, or if a new care plan is not effectively communicated during shift changes, the injury can rapidly progress. The failure to provide specialized pressure-redistribution mattresses or cushions for high-risk residents is another institutional failure that turns a predictable risk into a preventable injury.