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Introduction to Pressure Ulcers
Pressure ulcers, also known as pressure sores, bed sores or decubitus ulcers are areas of skin that have been exposed to significant pressure leading to skin damage.
Pressure ulcers are a cause of significant concern in healthcare and residential scenarios. They are known to be an international concern and plans and guidelines are in place to support the prevention and treatment of pressure ulcers.
The biggest cause of pressure ulcers is immobility, which means long periods in the same sitting or lying position. Even short-term immobility can lead to the development of pressure ulcers.
Fit and healthy people move approximately every 7 minutes to relieve pressure, which means they’re never in one place for too long.
The severity of the damage can range from reddening of the skin, (purple in those with dark skin) to large wounds which can expose muscles and even bones.
Pressure ulcers are costly both to the health care economy and the individual. About 700,000 people develop a pressure ulcer every year, which costs roughly £4,000 to treat correctly. The estimated daily costs of treating a pressure ulcer in the United Kingdom can range from £43 to £374 (Dealey et al 2012) which is about £1.4-2.1 billion annually.
The impact of pressure ulcers is significant as:
Pressure ulcers can be very painful and can even be life-threatening. It is important to prevent pressure ulcers and using pressure care equipment is an essential element.
Shelden Healthcare UK provides a range of pressure care equipment to support pressure ulcer prevention and management.
Two factors are normally responsible for the cause of pressure ulcers. External influences, which are those in the surrounding environment and internal influences, which are those relating to the person. i.e. their general health.
External factors that may cause pressure damage:
Pressure: is where the weight of the body is pushed against a specific area of skin. The force that leads to pressure ulcers is caused by heightened force on a specific area of the body or lower pressure over a longer period of time. The pressure reduces the blood supply to the skin and without the oxygen and nutrients that the blood brings, the skin dies.
Shear: is caused when the layers of skin are forced to slide over one another. This may be caused by moving the patient resulting in drag against a bed or chair. As the amount of shear increases the pressure leading to pressure ulcers is reduced.
Friction: is the rubbing of the skin. Inappropriate manual handling methods can remove the top layers (epidermis and dermis) of the skin resulting in superficial tissue loss. Repeated friction can increase the risk of pressure ulcers.
Issues to Consider In Relation to External Influences
Pressure: amount and the cause.
Duration of pressure : e.g. how long the individual remains in the same position.
Type of pressure/ shear/friction: e.g. from being moved across a bed.
Type of mattress being used: does this supports the pressure reduction and also the movement of the patient.
Seat or wheelchair: the design and height.
Level of care available: e.g. carer/staffing levels may mean that the individual can only be moved every 2 hours.
Education/information: supporting people with sitting correctly and explaining why frequent repositioning is important and can reduce the risks.
Positioning : in beds, chairs, in communal places such as TV rooms, dining rooms.
Issues to Consider In Relation to Internal Influences
Age: those over 65, neonates and very young children are at highest risk. However, a pressure ulcer can occur at any age and the biggest risk factor is immobility.
Health: if the individual has a chronic long-term condition or is unwell, they are at increased risk. Acute illness can cause changes in the body's normal functioning e.g. raised temperature, low blood pressure, constriction of the blood vessels. Chronic or terminal illness may result in reduced mobility or poor circulation and there are certain changes that occur in the skin at the end of life. Certain medications can also increase the risk, e.g. by increasing sedation.
Level of consciousness: if the individual becomes unconscious, they will not be able to change position to reduce pressure e.g. following surgery.
Weight: obese individuals are more at risk than those of normal weight because there is more weight on the pressure points – underweight individuals are also at risk.
Nutritional status: those who are malnourished or dehydrated are at a high risk. Poor nutrition can affect the elasticity of the skin and its ability to fight infection.
Previous history: individuals who have suffered from pressure damage in the past are more likely to develop pressure sores.
Mobility: patients who have reduced mobility or are immobile are most at risk because they are less able to relieve pressure by moving position.
Sensory functioning: individuals with sensory impairment (e.g. those unable to sense pain due to nerve damage or spinal injury) may not receive the stimulus to move to relieve pressure and are at greater risk.
Urinary or bowel incontinence: prolonged moisture on skin increases friction risks which lead to an increased risk of pressure ulcers.
Vascular disease: people with poor circulation due to damaged or partially blocked blood vessels are at increased risk of pressure damage. This is due to reduced blood volume and reduced flow of blood in the arteries and capillaries supplying the skin and underlying tissue
Anyone, young or old can develop pressure ulcers. The most important thing is the level of mobility and movement; which can reduce the risks either by the person or with the correct support.
People who are immobile or sit for long periods are at most risk, and while people can receive care, pressure care equipment is an essential part of pressure ulcer prevention.
It is critical that patients who are immobile are assessed by a doctor, nurse or a therapist (occupational therapist, seating therapist or physiotherapist) to ascertain their risk in order to establish a prevention plan based on SSKIN and to specify the appropriate pressure care equipment to prevent pressure ulceration.
The right pressure care equipment can help to prevent pressure ulcers for those with restricted mobility or immobility, so pressure care equipment should be selected very carefully.
Pressure ulcers can develop in any care setting including hospitals, care homes and even your own home.
The most common sites for pressure ulcers to develop are :
The other sites they can occur are:
Pressure ulcers can also develop when a medical device applies pressure to the body. Common causes are oxygen tubing, urinary catheters or splints. Other items such as shoes, spectacles and hearing aids may also cause damage. Carers need to check for this when looking after someone and any early signs of redness must be regarded as an alert for the need to re-position the device.
Pressure ulcers can also develop when a medical device applies pressure to the body and a common cause is oxygen tubing, urinary catheters or splints. Other items such as shoes, spectacles and hearing aids may also cause damage. People need to check for this when looking after someone and any early signs of redness must be regarded as an alert for the need to re-position the device.
You may have heard a nurse or other clinician mention SSKIN. It refers to a structured approach to care.
Surface - make sure people have the right support including mattress, chair, cushion and footwear. Remember to consider all the surfaces the patient will be in contact with
Skin – early inspection means early detection! Look for signs of redness and encourage people and carers to be alert to any skin changes and respond to them. .
Keep Moving – Encourage mobility or assist the person in changing position at least 2 hourly
Incontinence/Moisture – Patients need to clean dry skin to prevent pressure ulcers.
Nutrition/Hydration – Help People to have the right diet and plenty of fluids.
The skin is an amazing organ. Measuring around 2 square meters and accounting for up to 15% of your body weight – it is your body's largest organ.
The skin is made up of three layers:
The epidermis – this is the thin outer layer of the skin that everyone can see. It is less than half a centimetre and every 4 weeks is completely renewed as the outer cells are worn away and replaced with new ones.
The dermis – this lies beneath the epidermis, it is about half a centimetre thick and is the active part of the skin. It contains blood vessels, nerves, hair follicles, sebaceous oil, sweat glands and lymphatics. The dermis also contains collagen, fat and elastin fibres which give the skin its strength, stretch and flexibility.
The hypodermis – this is a layer of subcutaneous fat under the dermis. The thickness varies in relation to a person’s weight and also in different parts of the body. The hypodermis also contains blood vessels and connective tissue.
The hypodermis is important as it forms a protective layer over the underlying organs and structures; providing cushioning to protect the outer layers of the skin. The hypodermis also acts as an energy source for the body, providing insulation from outside temperature variations.
The skin has several different functions, but its main job is to protect the body.
Providing sensation – nerve endings within the skin can detect changes in temperature and pressure. They can also detect vibration and pain.
Regulating temperature – when the outside temperature rises, the body is cooled by the production and evaporation of sweat from the skin. Blood vessels in the skin dilate to increase blood flow near the surface of the skin, (this is why you go red when you get hot) so heat can be radiated away from the body. When the outside temperature falls, the skin tries to insulate the body.
Forming a physical barrier – the skin helps to shield the body from any damage including mechanical, thermal or chemical damage. It also protects you from Ultra Violet radiation, bacterial invasion and stops you becoming dehydrated.
Excreting waste products – the skin is one way in which the body gets rid of excess heat, water, salts and toxic organic compounds. Sebum an oily substance from the sebaceous glands is also secreted which helps to lubricate and protect the skin.
Metabolism – one of the skins important functions is to help in the production of Vitamin D. When your skin is exposed to sunlight, the Ultra Violet rays activate modify cholesterol in the dermis to produce Vitamin D. This is needed to help the body absorb calcium to form healthy bones.
Communication – we communicate through colour changes in our skin, blushing for example. The appearance of our skin is important because if damaged or abnormal in any way, it can affect an individual’s body image and quality of life.
Skin inspections should be carried out regularly; the frequency of which should be determined by the individuals level of risk (NICE 2014). Ideally, the individual should take responsibility for their skin condition, inspecting for any changes themselves, but for those who can’t do this, the carer should undertake responsibility. This will involve checking the skin over bony prominences (e.g. the heels, sacrum, and buttocks) and any other areas likely to be affected by pressure. The signs of early pressure damage that you should look out for:
Persistent reddening (Blanching erythema) – Reddened areas of skin that go white under light finger pressure are an early indicator of pressure damage. Preventative measures should be implemented to reduce pressure on the affected area. It may be hard to detect in dark or tanned skin, so wherever possible the person should be asked to identify areas of pain or discomfort as this could be an indicator of pressure ulcer development.
Never rub reddened skin as this may increase the risk of damage to underlying blood vessels and tissue. Care should also be taken with washing and cream applications which should be applied until the skin glistens.
If You Are Concerned About Patients Skin or Recognise Any of the Descriptions Below
it is important to contact a Doctor, Nurse or therapist for a full assessment and advice on care and pressure care equipment.
Category 1 Pressure Ulcer: Non-blanching Erythema – this is redness of the skin (erythema) which does not go white if you apply light finger pressure; it may also feel ‘boggy’. This indicates that damage has occurred due to unrelieved pressure. Other factors should also be considered such as:
The skin may feel warm to the touch.
Signs of swelling (oedema).
Solid or hardened tissue.
Individuals with Non Blanching erythema will need immediate interventions such as pressure relieving equipment and frequent turning/positioning to avoid reddened areas.
Category 2: A superficial wound that does not penetrate the deeper layers of the skin – these present as small red craters or clear blisters. These indicate that the epidermis has become separated from the underlying dermis – do not burst the blister, but implement pressure relieving care/techniques, and contact a healthcare professional for a full assessment and advice.
Category 3: Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. This may include undermining or tunneling. The depth varies by anatomical location, as there is very limited if any subcutaneous tissue on the heel.
Category 4: Full skin loss and extensive tissue damage with exposed muscle or bone or palpable tendon. Can extend into the muscle or supporting structures.
Deep & Ungradable: A deep wound with full thickness skin loss in which the actual depth of the ulcer is completely obscured by yellow debris (slough) or black (necrotic) tissue in the wound bed. Until enough slough/necrotic tissue is removed to expose the base of the wound, the true depth cannot be determined.
Suspected Deep Tissue Injury: Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage or underlying soft tissue. This area may be preceded by tissue that is painful, firm, boggy, mushy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin.
The appearance of the skin is an indicator of the state of an individual’s overall health and well being. The SSKIN principles actively encourage activities that help prevent pressure ulcer development, and skin inspection will identify the presence of existing or developing pressure ulcers, it can also support the application of care that will prevent skin breakdown and reduce the risk of potential pressure ulcer development.
The skin is affected by extremes of temperature, sun exposure, smoking, air conditioning and exposure to irritants and bacteria, so good hygiene practice is essential in maintaining healthy skin.
Skin should be washed gently but thoroughly, avoiding the use of highly scented soaps/products that may irritate the individuals skin causing rashes or allergic reactions that may blister the skin, or dryness reducing the skins suppleness and ability to stretch and may cause the individual to scratch, breaking the surface of the skin and it’s integrity.
The skin should be (gently) patted dry thoroughly, avoiding rigorous rubbing. Once dry, emollients can be applied to keep the skin moisturised and supple, this is especially important on dry skin. Good fluid intake is also important to protect the skin from becoming dry. Moisturised skin and good fluid intake will help prevent breaks and cracks in the skin.
Skin that is exposed to moisture from incontinence, leaking wounds or sweating (e.g. skin folds) is at risk of maceration and shear and friction forces, it should be protected by using a barrier product.
Clothing especially shoes/socks/slippers and undergarments should be well fitting, they should not be too tight or too loose as they will cause pressure or chaffing. It is important also to use the correct size manual handling equipment such as hoist slings and standing belts.
For people at risk of pressure ulcers or for those with pressure ulcers purchasing the appropriate pressure care equipment is very important. Pressure care equipment focuses on the 2 biggest causes of pressure ulcers: lying and sitting.
The available equipment includes Hospital type adjustable beds, pressure care mattresses, cushions and specialist seating. Pressure care accessories are also available including riser/ recliner chairs and other minor aids.
View our other pages on Hospital Beds and Mattresses: