Tissue Viability - Prevention of Pressure Ulcers

Introduction

Pressure ulcers are a widespread and often underestimated health problem. Even with the best possible medical and nursing care pressure ulcers can be difficult to prevent, especially for individuals who are at risk.

What is a pressure ulcer?

Pressure ulcers are an area of damage to the skin and tissue below that has occurred from sustained pressure. In very serious cases, the muscle and bone can also be damaged.

Pressure ulcers are caused by:

• Pressure – body weight can press down and squash the skin (for example, sitting in a chair or lying in bed for a long period of time without changing position and relieving the pressure). This reduces the blood supply and can lead to tissue becoming damaged
• Pressure in combination with shear – when layers of the skin are forced to slide over one another for example when you slide down in a bed or a chair

Who is at risk?

People may be at risk of developing a pressure ulcer if, for example, they:

• Have problems moving and cannot change position without help
• Cannot feel pain over part or all of their body for example due to diabetes or stroke
• Have a pre-existing health condition that affects the blood circulation system
• Are incontinent of urine or faeces
• Are seriously ill or undergoing surgery
• Have had pressure ulcers in the past
• Have a poor diet and don’t drink enough water
• Are elderly or very young
• Are obese or malnourished, underweight
• Are a smoker

Areas at risk

The areas at risk will change depending on the position you spend the majority of your time in. Use of heavy or tight blankets or clothing can exert pressure on the skin also.

Areas most at risk of developing ulcers are the parts of the body that are not covered by a high level of body fat and are in direct contact with a supporting surface, such as a bed, chair or wheelchair.

Pressure ulcers can sometimes develop from essential equipment used in your care, such as oxygen masks, urinary catheter or an orthopaedic splint/cast.

Symptoms

The first sign that a pressure ulcer may be forming is usually discolouration of the skin. This can initially appear as a red area of skin that does not disappear after a few hours and it may feel tender. It may not be red in those who have a darker pigmentation to their skin.

The area may become painful and purple in colour, which may get progressively worse and eventually lead to an open wound.

What to look for

•    Pain or discomfort to an area
•    Redness on pale skin or purple/bluish areas on darker skin
•    Heat or coolness compared to surrounding skin
•    Hardness or swelling to an area
•    Blistering or bogginess
•    Breaks to the skin, wounds or skin loss

What you can do

•    Keep moving and change position at least every 2 hours
•    Remove pressure from the risk areas using equipment or positioning
•    Eat well and drink plenty of fluids
•    Monitor your skin for any marks or changes to the colour and inform the staff of any concerns
•    Keep your skin clean and dry
•    Stop or reduce smoking

What the healthcare practitioner will do:

• Assess your risk of pressure damage, discuss your care with you and commence an agreed plan of care
• Assist you to keep moving and reposition you if needed (in community it may be a carer who helps you reposition)
• Provide equipment suitable for your needs, including mattress, cushion and heel protectors
• Inspect your skin daily at minimum and document any changes or if you are at home teach you or your carer how to inspect your skin daily
• Advise you on the use of protective creams for areas of risk. Moisturiser, soap substitute, barrier films and creams can protect the skin and keep it healthy
• Manage any wounds and apply dressings. Adhesive plasters or bandages will protect the wound and keep it clean

Preventing pressure ulcers

Changing position

• 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 will need to change their position at least once every 15-30 minutes
• People who are unable to leave their bed will need to change their position at least once every 2 hours
• If you are able to safely get up, stand for a couple of minutes or go for a short walk
• If you are unable to change position independently in hospital a member of staff will help you or in the community staff can show you and your carers how to reposition to offload pressure

Inspection and care of the skin

Regular inspection of high risk pressure areas is important to detect early signs of pressure ulcers and enables quick actions to stop them developing or getting worse.

To inspect awkward to view areas staff may use or provide hand held mirrors. A clean compact mirror can be useful to view your own pressure areas.

Nutrition and hydration

• The risk of developing a pressure ulcer is increased if you are malnourished or poorly hydrated. Therefore, eating a balanced diet can help prevent skin damage occurring and speed up the healing process
• Eat plenty of fresh fruit and vegetables along with protein rich foods such as; meat, fish, eggs and dairy products
• Drinking 8-10 cups of fluid (2000mls) per day is recommended to ensure you are properly hydrated. This doesn't have to be just water, tea, coffee, juice or squash are also fine
• A malnutrition risk assessment will be undertaken in hospital; if you are at risk of poor nutrition, you may be provided with snacks or dietary supplements and referred to a dietitian

Equipment

Pressure relieving equipment will not remove your risk of developing a pressure ulcer; it is essential that you continue to offload pressure and mobilise or change position whilst you are using equipment.

If you have any concerns over the equipment provided please speak with a healthcare professional.

Choosing the right pressure reducing equipment

It is very important that you are given the right type of pressure reducing/relieving equipment to suit your needs.

After a full assessment by your care team a decision will be made about which pressure reducing/relieving equipment best meets your needs. This will be discussed with you as part of your care plan.

What equipment is used?

High specification foam mattresses are specially designed to mould or contour around the body, cushioning bony areas.

High specification foam or gel filled seat cushions work in the same way and are designed to reduce/redistribute pressure whilst sitting in a chair.

Alternating pressure mattress

If the risk of developing pressure ulcers increases, or a pressure ulcer has already developed, your mattress may be changed to an alternating pressure mattress. This may be described as a dynamic, air mattress or electric mattress.

How do they work?

The inner part of the mattress is made up of tubes called cells.

The power unit motor fills the cells with air and continuously inflates and deflates them at regular intervals to provide pressure relief to each part of the body in turn.

If any of your equipment is not working or is alarming, please inform the staff immediately.

If you are at home, it is important that the District Nurse team be contacted immediately on the below contact number so that they can inspect it and arrange repair/replacement.

Heel protectors

If you are at risk of developing pressure ulcers to your heels, you will be provided with pressure reducing/relieving equipment specifically designed to protect this area from pressure.

These include inflatable boots, foam or inflatable wedge, foam leg troughs or silicone pressure reducing pads; these devices are specially designed to reduce/relieve pressure from that area.

If you do not find answers to your questions in this leaflet, please ask a member of staff.

For community use:

District nurse team …………………………………………………….

Contact Number………………………………………………………..