Pressure ulcers

Causes of pressure ulcers

Pressure ulcers happen if you are unable to move and stay in one position for a long time.

Constant pressure over a bony area of skin can stop blood from flowing normally and the skin breaks down. We normally move about constantly, even in our sleep. This stops pressure ulcers from developing.

People who are unable to move frequently tend to put pressure on the same areas of the body for a long time. If you are ill, bedridden or in a wheelchair, you are at higher risk of getting a pressure ulcer.

Several things can increase your risk of pressure ulcers, including:

• being unable to move around easily due to old age, illness, being unconscious, having a spinal cord injury or recovering from surgery

• weight loss - you may have less padding over bony areas

• sliding down in a bed or chair - pressure on the skin cuts off blood supply because the skin is being pulled or stretched in different directions. This is called shearing

• friction or rubbing of the skin, for example, against sheets

• a poor diet

• lack of fluid (dehydration)

• moist skin - for example, due to sweating or incontinence

• thin, dry or weak skin

• other medical conditions that can cause poor blood flow to the skin, such as diabetes and heart failure

• having had a previous pressure ulcer or scar tissue

• poor circulation due to smoking or vascular disease. Vascular disease is caused by inflammation and weakening of the network of blood vessels

• low levels of red blood cells (anaemia)

• medicines such as cancer drugs, NSAID drugs, steroids or blood thinners (anticoagulants)

Preventing pressure ulcers

It is much better to prevent pressure ulcers than to treat them.

Pressure ulcer prevention guidelines nationally recommend that a member of the healthcare team looking after you, should assess your risk of developing pressure ulcers. They should also create a plan to prevent them.

The areas of the body most at risk of getting a pressure ulcer depend on whether you are lying down or sitting.

The following diagrams show the area’s most at risk:

Tips to prevent pressure ulcers

The following tips can help to prevent pressure sores:

Relieving direct pressure

• Change position and keep moving as much as possible.

• If you have pain and find moving position painful ask for a painkiller before you need to move.

• Stand up to relieve pressure if you can.

• Ask your carer to reposition you regularly if you can't move.

• Change position frequently, how often depends on your situation. For example, it could be every 2, 4 or 6 hours.

• Use special pressure relieving mattresses and cushions.

• Don't drag your heels or elbows when moving in your bed or chair.

• Equipment is available to help you move in bed or to help you stand if you are sitting. Speak to your GP or healthcare team to find out more.

Skin care

• Check your skin regularly, if you can’t, get a carer or someone else to check for any skin changes.

• Keep your skin clean and dry.

• Avoid scented soaps as they can be more drying. A PH balanced soap or shower gel can be used.

• Moisturise your skin thoroughly after washing.

• Avoid using talcum powder as this dries the skins natural oils.

• Keep your skin well moisturised.

• Do not massage or rub the skin to prevent pressure ulcers.

• If you have continence issues, ask your health care provider for a skin barrier product to protect against skin breakdown.

General tips

• Make sure the bedsheets are smooth and not wrinkled when you are lying in bed.

• Sheets should be cotton or silk like fabric.

• Eat a well balanced diet.

• Keep hydrated - this means drinking at least 6 to 8 glasses a day. This includes water, milk, low sugar or sugar free drinks.

• Tell your doctor or nurse if you notice any skin changes or discomfort as soon as possible.

Diagnosing a pressure ulcer

Pressure ulcers develop when the skin breaks down and creates a wound. There is a risk that the wound can get infected. This can be a serious problem. It is very important to treat infections quickly.

A nurse or doctor must examine you. If you are at home district nurses can visit and advise on how to look after your skin. In hospitals, there are specialist nurses known as tissue viability nurses. They have specialist training in treating pressure ulcers. Your health care team can refer you to the tissue viability service and can advise you on the best treatment.

It can take a long time for pressure ulcers to heal.

Pressure ulcers are grouped into 4 categorises by your healthcare team or tissue viability nurse so they can work out how to best manage it.

Category 1 being the beginning of pressure damage and category 4 being the most severe pressure damage.

Signs of pressure ulcers

Signs of pressure damage usually occurs over a bony area that sticks out and can include:

• purplish or bluish patches on black or brown skin

• red or white patches on white skin

• when the skin mark is pressed it does not fade, disappear or change colour (non-blanching)

• soreness, itching or pain

• blisters

• swelling

• shiny areas

• dry patches

• cracks and wrinkles

• changes in skin temperature

• the texture of skin mark may feel firm, mushy or spongy (boggy)

Treatment of pressure ulcer

If you develop a pressure ulcer, it is vital to relieve pressure on the area. For example, it could be every 2, 4 or 6 hours, but this depends on your situation. The best way to do this is by not lying or sitting on the area affected for too long.

Mattresses and cushions

There are several types of special mattresses and cushions that can assist in relieving pressure. You will still need to move position throughout the day.

Some of the mattresses include:

• specially designed foam mattresses, which relieve the pressure on your body

• more sophisticated mattresses or bed systems. For example, a mattress connected to a constant flow of air. This automatically changes the pressure as and when needed

There are also many different types of cushions that are different shapes and contain different materials including:

• special types of foam

• air filled pockets

• a mixture of air filled and gel

Your healthcare team will tell you what the best types of mattresses and cushions are for your situation.

Dressings for pressure ulcers

If your skin has broken down, you will need to see a nurse to have this dressed. Contact your GP, practice nurse or district nurse for assessment and dressing of the pressure ulcer.

The dressing protects the area, keeps it clean, moist and helps it to heal.

There are different types of dressings, the one you need will depend on your wound. These could include:

• hydrocolloid dressings – these dressings contain a special gel. The gel helps with the growth of new skin cells in the ulcer. The dressing keeps the surrounding healthy area of skin dry

• alginate dressings – these dressings are made from seaweed. They contain sodium and calcium which helps to speed up the healing process

• other dressings include foams, films, hydrogel, hydrofibre, silicone, gelling fibres and antimicrobial (antibiotic) dressings

Your nurse will assess your pressure ulcer to decide which dressing is best for you. You have the dressing changed as needed and the nurse monitors how well it is working.

Other treatment for pressure ulcers

If you have a category 3 or 4 pressure ulcer, occasionally dead (necrotic) tissue around the ulcer can delay healing. You may need to have the necrotic tissue removed in a process called debridement. It can be done in different ways. This includes:

• your nurse removing the dead skin cells (slough) when cleaning your wound and changing the dressing

• a dressing designed to help remove the dead tissue

• the tissue viability nurse using a technique called sharp debridement. This involves removing the necrotic tissue from the wound to create a healthy wound for healing

These can usually be done on the ward, at home or at your GP surgery. Occasionally, when the pressure ulcer is deeper you may need to have an operation in hospital to remove the necrotic tissue and clean the wound. Not everyone is suitable for this and it is based on an assessment by a surgeon.

Other treatments may help in certain circumstances. Your healthcare team can tell you more about them.

They include:

• diet changes and supplements

• suction treatment to remove excess fluid from the wound. You may hear it being called VAC therapy or topical negative pressure

• sterile maggots (larvae) placed onto the wound. They are very good a removing dead cells and cleaning the wound. This would be advised on individual basis by a specialist