PRESSURE ULCER PREVENTION

A pressure ulcer is a localised area of cellular damage resulting from direct pressure on the skin causing ischaemia (lack of blood) or from shearing or friction forces causing mechanical stress on the tissues.

Main Causes

PRESSURE – damage occurs when skin and other tissues are directly compressed between bone and another surface such as a bed or chair. The small blood vessels become squashed and this slows down or cuts off the blood supply.

INTENSITY AND DURATION – low pressure can cause tissue damage if it is sustained over several hours, whereas very high pressure can cause damage within minutes.

FRICTION – damage occurs when the skin rubs against another surface e.g. heels or elbows rubbing on the sheets.

SHEARING – damage occurs when tissues are wrenched in opposite directions e.g. by slipping down the bed or chair.

Risk Factors

BODY SHAPE AND SIZE – Thin people have no fatty padding over bony prominences and so have less protection against pressure. Obese patients can find it difficult to move which can lead to tissue damage. Fatty tissue also has a poor blood supply, it is less resilient and more prone to shearing forces. Skin can be hot, sweaty and fragile making the risk of breakdown ever greater.

MOBILITY – Patients who are immobile or have reduced mobility are the ones with the most significant risk factor in pressure ulcer development. Sensory impairment means that patients have reduced sensation and can therefore be insensitive to pain and discomfort e.g. Stroke, Multiple Sclerosis, Diabetes, Terminal illness, Arthritis.

AGE – Patients over 65 years are at greater risk. Their skin becomes thinner and less elastic with age. Often there is an increase in neurological and cardiovascular disease. Women are twice as likely to develop a pressure sore than men.

ILL HEALTH – The heart, blood pressure and breathing all effect the circulation, which in turn will affect the blood supply to the tissues e.g. arteriosclerosis, congestive cardiac failure. Swollen feet, ankles or bottom makes that area less resistant to pressure. Infection, high temperature and sweating can all increase the risk of pressure sore development as skin loses its suppleness. A patient who smokes is at higher risk of developing heel sores, because the nicotine causes vasoconstriction (narrowing of the blood vessels) especially peripherally (hands and feet). Chronic and terminal illness e.g. diabetes, cancer are at risk. Medication is another factor to put patients at risk e.g. diuretics, sedatives, steroids and cytotoxic drugs.

SKIN AND HYGIENE –It is important to keep fresh, clean and dry.

NUTRITION – poor hydration due to low fluid intake or high fluid loss e.g. diuretics, diarrhoea and vomiting, will lead to less resistance and lower elasticity of the skin. Poor nutrition is a high risk factor, especially lacking protein, as this is needed for new growth. Vitamin and mineral deficiency – lack of iron and B12 can lead to anaemia and therefore will lead to reduced oxygen levels in the blood. Vitamin deficiency can lead to lower integrity of the cell walls. Pain, communication difficulties, dementia, apathy, disease and depression are reasons why a patient may lose interest in food.

INCONTINENCE – skin has a natural barrier of oils to help protect is, so washing with strong soaps can strip this protective layer away, and can lead to dehydration of the skin and increase the risk of friction sores. Do not rub fragile skin, pat it dry. Faeces and urine on the skin can lead to pressure sore development as it can mascerate the skin and tissue damage from friction becomes more likely.

Stages of a Pressure Ulcer

Pressure ulcers can begin to develop in a short time. It is important that you look for signs of damage so preventative measures can be taken at the early stages. Early signs of skin damage include a change of colour. It may be red or darkened.

If you notice a reddened area after repositioning, the area should be observed again after 30minutes has elapsed. If the redness is still there, even though the area has been relieved of pressure, it may suggest the early signs of an ulcer. The majority of pressure ulcers can be reversed at this stage by more frequent change of position. If missed it could lead to an open wound. Please contact the District nursing team for further advice as needed.

Preventing Pressure Ulcers

MOBILITY - It is extremely important to move or be moved. Try to change your position every two hours. If you are confined to bed, you can change from lying on your back to your sides.

Pillows can be useful to protect areas at risk, such as between your knees and ankles.
The objective of correct positioning is to take pressure away from bony areas of your body and onto more fleshy ones.

It is important to maintain good posture when sitting and not to slouch. If you spend a long time in a chair or wheelchair, take the weight off your bottom by easing yourself up on your arms or by rocking from cheek to cheek for a short while, or by reducing the length of time sat to 2 hours.

SKIN INSPECTION - Regular visual inspection of the skin is important to ensure any early signs of damage are detected. Look for skin that is red or dark in colour, and which does not return to normal when you take your weight off it. It may be purplish/bluish on darkly pigmented skin. Here may also be localized heat and swelling.

Wash skin with a gentle soap and rinse off all traces. Pat your skin gently to dry. Wash and dry skin between pad changes.

Take care to avoid sitting on crumbs in the bed or creases in the bedclothes. Be careful using talcum powder, as they will soak up the natural oils in your skin and leave it dry.

NUTRITION - Eat a healthy diet. Protein, Vitamin C and Zinc are particularly effective for maintaining healthy skin. A glass of fresh orange juice each day is a good source of vitamin C and will help to absorb protein.
Drink plenty of fluids (about 1.5litres a day), as this will keep your skin and muscle supple.

EQUIPMENT - There are a number of special equipment available to help prevent pressure ulcers. Ask your nurse, occupational therapist, wheelchair centre or health equipment store.

INFORMATION BOOKLET AND ADVICE AVAILABLE FROM THE DISTRICT NURSING TEAM.