Groups » How-To Guide: Understanding and Treating the 4 Stages of Bedsores

Bed sores are a common problem among bedridden patients, particularly senior citizens. Usually, too much pressure on a particular area of the skin for a long period of time can lead to the development of pressure ulcers. The lack of oxygen and blood supply due to excessive pressure is the primary cause of bed sores. That's why shoulder blades, tailbone, elbows, heels and hips are the most commonly affected areas. Though healthcare providers take necessary pressure sore prevention steps, senior patients still face the risk of developing them.

Depending on the severity of symptoms, there are four stages of bedsores. As it happens, the severity of symptoms can lead to various degrees of life-threatening health issues. Going from the least severe to the worst, they become progressively difficult to treat. It is necessary to understand what type of pressure ulcers you or a family member has to receive proper care.

1) Stage I
Though at this stage the pressure ulcer has just begun to develop, the affected area can be painful. The skin doesn't show any breaks or tears, but reddened spots may appear in the affected area. It can also show a change in the hardness and temperature compared to normal skin, by appearing warmer or cooler, firmer or softer than the surrounding skin. When you put pressure on the affected area, it remains red and doesn't turn white or become blanch. In dark-skinned patients, the ulcer may not appear red, but may show spots of a different color compared to their normal skin tone.

2) Stage II
The breakdown of the topmost layer of skin or the epidermis usually marks the beginning of the second stage. The skin damage can manifest itself in the formation of a shallow open wound that looks like a blister, abrasion or even a small crater. It appears red or pink in color and may damage the second layer of skin or dermis. In a few cases, fluid leakage (pus formation) can also be found in the affected area. As compared to the earlier stage, the patient may suffer from more pain and irritation.

3) Stage III
At this stage, the wound penetrates beneath the second layer of skin (dermis) resulting in a deep crater. The wound is deep enough to expose the fatty subcutaneous tissue, but the bone, the tendon, and the muscle are not visible yet. You may see redness around the edge of the affected area with strong odor, pus, and greenish secretion.

4) Stage IV
The wound extends into the muscle, the tendon, and even the bone. At this stage, the patient may not feel any pain due to extensive tissue damage and formation of dead skin or necrosis. The possibility of osteomyelitis (bone infection) or sepsis (blood infection) also increases if pressure sores are left untreated at this stage.

5) Unstageable Pressure Ulcer
Usually, decubitus ulcers covered with slough or eschar (mass of dead tissue) are known as unstageable. Sometimes the base of the pressure ulcer is covered by a thick layer of the dead tissue and pus of yellow, tan, gray, green or brown color, making it difficult for physicians to determine the exact stage of the bed sores.


Though it is possible to treat bedsores with thorough and comprehensive medical management, nursing home and healthcare providers must take proper precautions for bedsore prevention. Usually, treatment in stage I and stage II pressure ulcers doesn't require surgical intervention, unlike the treatment in stage III, stage IV, and unstageable ones.

The treatment primarily focuses on three factors:

1) Reducing wound pressure
2) Controlling infection
3) Removal of dead tissue (wound debridement)

1) Reducing Wound Pressure

This involves minimizing pressure, shear, and friction as all of these elements can cause extensive tissue damage.

  • Use pressure-relieving devices and supports such as mattresses, bed covers, and chair cushions designed to reduce and spread the pressure.

  • Avoid sliding, slipping or rubbing, especially if it puts direct pressure on existing pressure sores.

  • Prepare a regular schedule for position changes and stick with it. Change the position of a patient who is confined to the bed every couple of hours. The position of wheelchair-bound patients should be changed every fifteen minutes, if possible.

  • Check the patients from head to toe every other day to see if new bedsores have developed. This is particularly for patients who are obese and/or have delicate skin.

2) Controlling Infection

Controlling infection and promoting healing involves cleaning, covering and keeping the affected area slightly moist. Regular cleaning will also help reduce the pain and odor.

  • For stage I pressure ulcer, a mild cream or lotion can be used to keep it moist as the skin is still intact.

  • Though several different cleansing products are available, saline is often used for cleaning the wound. However, the physician may advise you to use a special cleansing solution.

  • Avoid using an antiseptic solution for cleaning the wound as it can damage the exposed tissue.

  • An antimicrobial silver foam dressing, a silver alginate dressing, or a combination of both can be used to prevent infection. However, you may have to use several different dressings over the course of treatment, as recommended by the doctor.

3) Wound Debridement

  • The purpose of wound debridement is the safe removal of dead or devitalized tissue to determine the exact stage of the bed sores. Debridement (removal of dead tissue) is often carried out as per your doctor's recommendations.

  • Depending on the circumstances, physicians will use surgical, mechanical, enzymatic and/or autolytic techniques for removal of devitalized tissue.

  • However, heel ulcers with dry eschar are not debrided just for the sake of staging because eschar serves as a protective cover.


Despite several precautionary measures taken by healthcare providers, bedsores continue to prevail among senior patients who have limited ability to change their positions. It is a matter of concern for not only bedridden

patients, but their family members and healthcare providers as well. Bedsores occur in four stages with various degrees of symptoms that may lead to life-threatening infections. This staging process often helps doctors and nurses to create a long-term treatment plan.

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