Which of the following interventions is the most important in preventing pressure ulcers?

Pressure sores are wounds that develop when constant pressure or friction on one area of the body damages the skin. Constant pressure on an area of skin stops blood flowing normally, so the cells die and the skin breaks down.

Other names for pressure sores are bedsores, pressure ulcers and decubitus ulcers.

Causes of pressure sores

Pressure sores happen if you can’t move around and so stay in one position for a long time. We normally move about constantly, even in our sleep. This stops pressure sores developing.

People who are unable to move around 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 risk of getting pressure sores.

A number of things can increase your risk of pressure sores, including:

• being unable to move around easily due to old age or illness
• 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 in different directions (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
• other medical conditions, such as diabetes
• having a previous pressure ulcer

Preventing pressure sores

It is much better to prevent pressure sores than to treat them. The National Institute for Health and Care Excellence (NICE), Healthcare Improvement Scotland and the European Pressure Ulcer Advisory Panel (EPUAP) have guidelines on pressure sores.

They all recommend that a member of the health care team looking after you should assess your risk of developing pressure sores and create a plan to prevent them. 

The areas of skin most at risk of getting sore depends on whether you are lying down or sitting. The following diagrams show the areas most at risk:

Tips to prevent pressure sores

The following tips can help to prevent pressure sores:

Relieving direct pressure

• change position and keep moving as much as possible
• stand up to relieve pressure if you can
• ask your carer to reposition you regularly if you can't move
• change position at least every 2 hours
• use special pressure relieving mattresses and cushions
• don't drag your heels or elbows when moving in your bed or chair

Skincare

• keep your skin clean and dry
• avoid scented soaps as they can be more drying
• moisturise your skin thoroughly after washing
• avoid using talcum powder as this dries the skins natural oils
• keep your skin well moisturised

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
• have at least 2 litres of fluid a day
• tell your doctor or nurse if you notice any skin changes or discomfort as soon as possible

• Overview
• Symptoms and Causes
• Diagnosis and Tests
• Management and Treatment
• Prevention
• Outlook / Prognosis
• Living With

Overview

What is a pressure injury?

A pressure injury (also called a bedsore, pressure ulcer, pressure sore, or decubitus ulcer) is an area of injured skin. A pressure injury happens when force is applied on the surface of the skin. This force can be a constant pressure on an area of skin or a dragging (shearing) force between the skin and another surface. These injuries usually happen over bony parts of the body (hips, heels, tailbone, elbows, head and ankles). A pressure injury can become life-threatening if it advances to a deep wound or becomes infected.

What are the stages of a pressure injury?

There are four stages that describe the severity of the wound. These stages include:

• Stage 1: This stage is discolored skin. The skin appears red in those with lighter skin tones and blue/purple in those with darker skin tones. The skin does not blanch (turn white) when pressed with a finger.
• Stage 2: This stage involves superficial damage of the skin. The top layer of skin is lost. It may also look like a blister. At this stage, the top layer of skin can repair itself.
• Stage 3: This stage is a deeper wound. The wound is open, extending to the fatty layer of the skin, though muscles and bone are not showing.
• Stage 4: This stage is the most severe. The wound extends down to the bone. The muscles and bone are prone to infection, which can be life-threatening.

Who is at risk for developing pressure injuries?

• People with a limited amount of mobility or a total inability to move. Those in wheelchairs or bedridden are at particular risk and need to be moved or turned regularly.
• Those with prosthetic (artificial) limbs. If the device does not fit properly, the skin can be irritated and a pressure injury can develop.
• People with a loss of sensation. They are at risk because they may not feel the pressure being applied to the skin. As a result, they may not move, which could worsen the damage.
• Those with malnutrition. Wound healing is slowed when nutritional needs are not met.
• The elderly. As people age, the skin naturally becomes thinner and more easily damaged.

Symptoms and Causes

What are the causes of pressure injuries?

Pressure injuries are caused when a force is applied to the skin, causing damage to the tissue. Several types of force include:

• Pressure: Constant pressure on the skin results from remaining in the same position for a prolonged period of time.
• Shear: Shear damage or a dragging force can occur when the head of the bed is raised and the body slides down. The skin sticks to the sheets, but internal structures are damaged.
• Moisture: Fluids (sweat, urine, fecal matter) that remains on the skin can cause the skin to become overly wet, which increases the risk for pressure injury development.

What are the symptoms of pressure injuries?

The symptoms of pressure injuries can include:

• Changes in skin color (non-blanchable redness in lighter skin tones and non-blanchable blue/purple skin in darker skin tones)
• Skin swelling, pain or tenderness
• Skin that feels cooler or warmer to the touch than other areas
• Skin loss, exposing deeper layers of skin
• Pus-like drainage from an open area of skin

Diagnosis and Tests

How are pressure injuries diagnosed?

Pressure injuries are diagnosed by your healthcare provider during a physical exam.

Management and Treatment

How are pressure injuries treated?

Pressure injuries can be treated in many ways depending on the stage. Once the stage and severity of the wound is determined, it must be cleaned, usually with a saline solution. After the wound is cleaned, it needs to be kept clean, moist, and covered with an appropriate bandage. There are several different types of bandages your doctor may use to dress the wound. These include:

• Water-based gel (hydrogel) with a dry dressing
• Foam dressing
• Hydrocolloid dressing
• Alginate dressing (made from seaweed)

Sometimes debridement is needed. This is a process of ridding the wound of dead tissue. Debridement is an important part of the healing process. It changes the wound from a long-lasting (chronic) one to a short-term (acute) wound. There are several types of debridement. These methods include:

• Ultrasound: Using sound waves to remove the dead tissue.
• Irrigation: Using fluid (often pressurized) to wash away dead tissue.
• Laser: Using focused light beams to remove the dead tissue.
• Biosurgery: Using maggots to eliminate bacteria from the wound.
• Surgery: Using surgery to remove the dead tissue and close the wound.
• Topical: Medical-grade honey or enzyme ointments.

Prevention

How can pressure injuries be prevented?

The development of pressure injuries can be prevented through careful observation of the skin and frequent repositioning in those who can’t turn themselves. Tips to prevent pressure injuries include:

• Keeping the skin clean and clear of bodily fluids.
• Moving and repositioning the body frequently to avoid constant pressure on bony parts of the body.
• Using foam wedges and pillows to help relieve pressure on bony parts of the body when turned in bed.
• Maintaining a healthy diet to avoid malnutrition and to assist in wound healing.

Outlook / Prognosis

What are the long-term consequences of a pressure injury?

If the wound becomes infected, the infection can spread to other parts of the body. Several conditions that may occur if an infection spreads include:

• Cellulitis: An infection of the skin.
• Osteomyelitis: An infection of the bone.
• Bacteremia: An infection of the blood.
• Meningitis: An infection of the brain and spinal cord.
• Endocarditis: An infection of the heart.

Living With

When should I call the doctor?

If you suspect you have a pressure injury, speak with your doctor. A pressure injury is easier to heal if it is discovered in the early stages. It is important to prevent a wound from becoming infected. Healing is delayed in an infected wound and the infection could cause problems in other areas of the body.

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