Pressure ulcer prevention

A pressure ulcer is damage to the skin and the deeper layer of tissue under the skin. This happens when pressure is applied to the same area of skin over a period of time and cuts off its blood supply. It is more likely if a person has to stay in a bed or chair for a long time. Pressure ulcers are sometimes called ‘bed sores’ or ‘pressure sores’.

Apart from continued pressure on an area the following may also cause pressure ulcers

• Sliding or slumping  down a bed or chair. This can cause damage to the skin and deeper layers of tissue by shearing
• Poor moving and handling methods can create friction and cause the removal of the top layer of skin or blisters

Without care pressure ulcers can become very serious, leading to damage to the muscle or bone underneath the skin and life threatening infections. They can take a very long time to heal.

To prevent pressure ulcers getting worse it is extremely important that they are treated as soon as they appear.

Anyone can get a pressure ulcer but some people are more likely to develop one than others (they might be referred to as at risk). You might be more at risk if you:

• Have problems moving or changing position without help
• Cannot feel pain over all or part of your body
• Have problems controlling your bladder or bowels
• Are seriously ill
• Have had an operation
• Have had an epidural or medications which reduce your ability to move and sensitivity to pain
• Have had a pressure ulcer before
• Have existing broken skin
• Have poor circulation
• Have a poor diet and don’t drink enough water
• Have problems with memory and understanding (such as with dementia)
• Have an injury that affects how you move

There are lots of other reasons why you might be at risk. If you are at risk of developing a pressure ulcer your health care professional will explain the reasons for this.

Some people are at ‘high risk’ of developing pressure ulcers. The more problems listed above that you have the more likely you are to be high risk.

If you are admitted to hospital or go into a care home you should be assessed to see whether you are at risk as soon as possible after your admission. If you are seen by a district nurse in your own home you will also be assessed. 

As part of your treatment plan your care team will discuss with you the best way to prevent pressure ulcers. This will depend upon you as an individual.

Check your skin twice daily and look out for the following signs:

• Changes in skin colour, red patches on light skinned people and bluish/purple patches on dark skinned people
• Bluish/purple discolouration in lighter skinned people indicates possible damage to the deeper layers of tissue
• A feeling of heat or coolness in the area
• Swelling
• Discomfort or pain
• Blistering
• Any other skin damage

Using a mirror can be useful for checking parts of your body that are hard to see for example back or buttocks.

Remember, there are many things which can put pressure on the skin such as oxygen masks, tight shoes and clothing, wheelchair foot plates/arm rests and eye glasses.

If you have diabetes pay particular attention to your feet or ask someone else to do it.

If you or your carer requires any further advice or training in how to check for or prevent pressure ulcers please do not hesitate to ask.

If you notice any possible signs of skin damage, even if you don’t think it is a pressure ulcer you should contact your nurse or healthcare team immediately.

Your healthcare professional will advise you on how to make sure that surfaces such as mattresses, cushions, heel protectors and pillows are appropriate to you as an individual. Mattress protectors and fitted sheets should not be used with pressure relieving equipment as they may reduce its effectiveness.

There are products which are available but will not prevent pressure ulcers and in some cases may increase your risk of developing a pressure ulcer. These include rubber rings ‘doughnut’ rings, fibre filled overlays, artificial sheepskins and domestic cushions.

Make sure all sheets are crease and crumb free and that there are no objects in the bed or chair which might cause pressure for example TV remote control.

Making regular and frequent changes to your position is one of the most effective ways of preventing pressure ulcers. As a general rule wheelchair users or people sitting for long periods in a chair will need to change their position every 15 to 30 minutes people who are confined to bed once every 2 to 4 hours.

If you are unable to change position yourself a carer or relative can help to reposition you. It is important that if carers move you in bed they must use a slide sheet.

If they move you in a chair they must assist you to stand or use a hoist. You should not be pulled up the chair.

Once your risk assessment is complete your health care team will advise you on how often you need to be moved. This will be done with discussion and agreement with you.

A healthcare professional will also give you training and advice about:

• Correct sitting and lying positions
• How you can adjust your sitting and lying position
• How best to support your feet and heels
• How to keep a good posture
• How to use any special equipment.

It is important to remember that specialist mattresses and cushions do not replace movement. 

Prolonged exposure to moisture makes the skin more vulnerable to developing pressure ulcers. Good personal hygiene is vital but soap can dry out the skin. Avoid using baby wipes and use a mild soap ideally with a pH balance of 5.5 and gently pat your skin dry. Avoid vigorously rubbing or massaging your skin.

The risk to your skin from incontinence (unintentional passing of urine or faeces, or both (known as double incontinence)) can be reduced by your healthcare professional assessing you for a suitable aid or appliance. Your healthcare professional can also provide advice on the use of barrier products. 

Eating well and drinking enough water is very important. In addition to the fluid from your food you need to be drinking at least 6 to 8 drinks per day.

A healthy diet that contains an adequate amount of protein and vitamins and minerals can help prevent skin breakdown and speed up the healing process. 

If you have a poor appetite

• Eat smaller portions of food more often
• You may find that you are put off by cooking smells, if this is the case avoid them wherever possible
• Choose full fat options for milk, yogurt, butter and cheese etc. and avoid low fat foods where possible
• Drink regular nourishing drinks such as milky coffee, tea or malted drinks

Try to eat 5 portions of fruit and vegetables per day as they contain a wide range of vitamins and minerals essential to keep your skin healthy and aid wound healing.

Ask your healthcare professional for advice.

Are you eating a healthy diet?

The eatwell guide (NHS.UK) shows the different types of food we need to eat and in what proportions to have a healthy diet.

Weight has been shown to be a significant risk factor for pressure ulcer development. If you are underweight the bony areas of your body become more prone to skin damage. Maintaining a healthy weight provides padding however being obese is also a risk factor.

If you are concerned that you may be under or over weight your health care professional or GP can provide you with further advice or refer you to a dietitian.

Diabetes if poorly controlled can affect the condition of your skin and slow down healing. It is important that you follow all the instructions you have been given about your diet and medication. If you have any concerns contact your GP, practice nurse or diabetes nurse.