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Preventing Pressure UlcersAn information booklet for patients

Published by the Metropolitan Health and Aged Care Services DivisionVictorian Government Department of Human Services, Melbourne Victoria

October 2004

This booklet is also available in PDF format and may be downloaded from the VQC website at http://www.health.vic.gov.au/qualitycouncil/

© Copyright State of Victoria, Department of Human Services, 2004

This material may be freely reproduced for educational and not for profit purposes.

Disclaimer: This health information is for general education purposesonly. Please consult with your health professional to make sure theinformation is right for you.

Victorian Quality Council SecretariatPhone 1300 135 427Email [email protected] www.health.vic.gov.au/qualitycouncil

What is a pressure ulcer? 3

Stages of pressure ulcers 3

Why are they important? 3

Who gets pressure ulcers? 3

Assessing your risk 3

How do pressure ulcers start? 4

Where are they found on the body? 5

How can you prevent pressure ulcers? 6

Move, move, move 6

What to do if you have limited movement 6

Special equipment 8

Look after your skin 9

Pressure ulcers in the past 9

Loss of bladder and/or bowel control 9

Sensory changes 9

Poor circulation 10

Foot care 10

Eat a balanced diet 11

Smoking 11

How to recognise the early warning signs 12

The signs to look for 12

The signs to feel for 12

PREVENTING PRESSURE ULCERS

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Con

tent

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Preventing Pressure Ulcers


You have been given this booklet because you have been identified ashaving an increased risk of developing a pressure ulcer, you have had apressure ulcer in the past or because you currently have a pressure ulcer.

This booklet will tell you more about pressure ulcers – what they are,how they start, how you can prevent them and how to recognise theearly warning signs.

This booklet is designed for patients, but also providesuseful information for carers.

If you want further informationabout preventing pressure ulcers, ask your nurse orhealthcare professional.

Comment from Brian Johnson –a patient who developed apressure ulcer.

“I was told frequently to “pushmyself up in the bed with mygood foot”. As I have little feelingin my feet I didn’t realise thedamage was occurring (in myother foot).

I was housebound for manymonths...and the heel tookapproximately 12 months to healand I still have scar tissue.”

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What is a pressure ulcer?A pressure ulcer is a sore, an area of skin that has been damaged due to unrelieved and prolonged pressure.They are also known as pressuresores or bed sores.

Stages of pressure ulcersPressure ulcers are grouped into fourstages, depending on how deep theulcer is. You might hear medical andnursing staff referring to your pressureulcer as a Stage 1, 2, 3 or 4. Stage 1ulcers are less severe while a Stage 4is more severe.

Why are they important?Pressure ulcers can happen quickly,so it is important to heed warningsigns and act swiftly to prevent them occurring or becoming worse.Pressure ulcers can affect your healthand slow your recovery. They can leadto a longer stay in hospital.

Pressure ulcers often look to be minor,just redness in the skin to begin with,but they can hide more damage underthe skin’s surface. Pressure ulcers can be painful and they can becomeinfected, sometimes causing bloodpoisoning or bone infections. In severecases, they can spread deeply underthe skin and some of the underlyingmuscle or bone may be destroyed.

Who gets pressure ulcers?You can be at risk of getting apressure ulcer if one or more of thefollowing situations relates to you:

You are confined to bed or a chair and unable to moveyourself independently or havelimited movement

You have loss of sensation or poor circulation

You have skin that is frequentlymoist through perspiration or loss of bowel or bladder control

You have poor nutrition

You are unwell

Assessing your riskTo assess your risk of developingpressure ulcers, a staff member willexamine you and ask you certainquestions about your general health,your skin and your ability to moveindependently. This is called a ‘riskassessment’. Together you can workout the best plan to prevent or reducethe risk of you getting a pressure ulcer.


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How do pressure ulcers start?Blood vessels supply oxygen andnutrients to every part of the body,including the skin. Constant pressurein one area means that blood andnutrients are less able to reach theskin in this area.

Imagine the blood vessel is like agarden hose. If you put your foot onthe garden hose, the pressure of yourfoot stops the water from gettingthrough. If the bones inside your bodyput too much pressure on the bloodvessels, then the blood cannot getthrough and this can cause damageto your skin and other tissues.

If the pressure of normal body weightis not relieved in people at risk, it canharm the blood supply to the area, whichcan lead to skin and tissue damage.

Although unrelieved pressure is themain cause of pressure ulcers, acombination of other factors such as friction (from rubbing, dragging)and shear (sliding down the bed) can also contribute to skin damageleading to a pressure ulcer.

Poor lifting and moving techniquescan remove the top layers of skinthrough friction with the bed or chairsurfaces. Repeated friction canincrease the risk of pressure ulcers.

Sliding forces (shears) the upper layersof skin away from the deeper layers.This can happen when you slide down,or are dragged up, a bed or chair.

If you experience limited movement,constantly moist skin, changes insensation, poor circulation and poor nutrition these factors can alsocontribute to pressure ulcers occurring.


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Heel showing shearing and friction

Heel boneBlood supply

Surface

When sitting:tail bone (coccyx)

buttocks (ischium)

backs of heels

elbows

shoulder blades

When lying on your back:the back of your head

shoulder blades

elbows

tail bone (coccyx)

heels

toes

When lying on your side:ear

side of your shoulder

pelvis

hip

knee

ankle bones (malleolus)

Where are they found on the body?Pressure ulcers are usually found on bony parts of the body, but can occuralmost anywhere that pressure has been applied for a period of time. They aregenerally found where bones are close to the skin and where the skin pressesagainst a firm surface, such as a chair or mattress.

These diagrams show you where pressure ulcers occur in various positions or postures.


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How can you preventpressure ulcers?The three most important ways to prevent pressure ulcers are to:

Move, move, move –to relieve the pressure

Look after your skin

Eat a balanced diet

Move, Move, Move

What to do if you have limited movementWhen you are unwell, or less mobile,it can be difficult to change position or to move around by yourself. Beloware some ways you can help to reduceyour risk of getting a pressure ulcer. It is important to keep moving, asexercising increases blood flow to the skin, muscles and joints. A nurseor physiotherapist can advise you onexercises you can do while you arerecovering.

While you are lying in bedTurn yourself at least every hour,more frequently if you are not on a support surface or specialisedequipment. If you are unable tomove yourself, ask the staff to helpchange your position regularly.

When you lie down, your headrestand foot section of the bed shouldbe level. Your body should be tiltedslightly to the side (around a 30°angle) and supported with pillows.This will remove pressure fromyour tail bone and your hips andput the pressure on a more fleshypart of your bottom.

Keep the pressure off your lowerleg by bending your knees a littleand putting a pillow in betweenyour knees and ankles.


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✓

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Lying 30° side tilt

Make sure you are lifted correctly, notdragged, when changing position.

Wear long sleeved clothing as well as socks. Ask staff to use a ‘slide sheet’ between you and the surface of the bed or chair to help reduce friction.

Avoid sitting on creases in sheetsor clothes, and avoid leaningagainst zippers and buttons.

If you do raise the head of the bed,keep it below 30°; otherwise youwill tend to slide down in bed whichcan damage your skin through frictionand shear. It can help if you have a bed that can raise the mattressunder your knees a little as this willhelp prevent you from sliding down.

It is important to sit up while eating to prevent choking and to aid digestion. However, only situp in this position for half an hour.

While you are sitting in a chair

Good posture is important, soavoid sitting in a slumped position.Sit up straight with your bottom wellback in the chair and with yourback touching the back of the chair.Support your feet so that your kneesare level with your hips. Never haveyour knees higher than your hips.

When you are sitting down, liftyour bottom up from the chair for 15 seconds. Do this every 15 minutes. This is also importantif you sit on the toilet or commodechair for long periods, make sureyou lean forward every 15 minutesto relieve pressure from your bottom.Lean forward while seated if youhave a pressure sore oruncomfortable area.


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Sitting correctly

Lying 30° head tilt

Push yourself up off the chair usingthe armrests, leaning to the side,or by lifting one buttock off theseat at a time.

Avoid leaning to one side for any length of time – the pressureincreases on both your buttocksand your elbow.

If you find you still slide forward in your chair, ask to see anOccupational Therapist (OT) whocan suggest chair or cushioningalternatives to keep you in anupright position.

Lie down to rest during the day –this will give your bottom a breakfrom the pressure.

Special equipmentIf you are at high risk of getting apressure ulcer, staff may use a rangeof special equipment to help reducethe pressure from particular places.These may include air or dynamicmattresses, cushions and heel wedges.


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Sitting incorrectly

Look after your skinSkin grows thinner and less elasticwith advancing age. The layer of tissueand fat under the skin also reduces in thickness. This means that bloodcirculation is less protected, and as a result, it is easier to damage yourskin as you get older.

Try and keep your skin clean anddry at all times. Let staff know ifyour clothes or bedding are damp.

Check your skin regularly. Use amirror for any areas that are difficultto inspect. If you are unable to dothis staff will inspect your skin foryou as part of your pressure ulcerprevention plan.

Use a moisturising lotion to preventskin drying out and cracking andprotect your skin from dry or cold air.

Bathe or shower in warm (not hot)water using a mild cleanser or soap.Dry your skin gently to preventfurther damage to the skin.

Avoid massaging your skin overbony parts of the body.

Pressure ulcers in the pastIf you have had a pressure ulcer in the past the scar tissue in that area is weaker and more prone to furtherdamage. After a pressure ulcer heals,the new skin does not have the samestrength as the original. The new skinis only 80% as strong as it was.

Loss of bladder and/or bowel controlWhen moisture and other substancessit on your skin for a period of time, it provides bacteria a place to grow.When bacteria sit on the skin for any length of time, it can irritate andfurther damage the skin.

If you use a continence appliance,check it regularly and change itwhen necessary.

If you have problems with yourbowel or bladder, clean your skinas soon as it is soiled or ask staffto assist you. If you need moreinformation about how to manageincontinence ask your nurse.

Sensory changesSome medical conditions can changeyour perception of pain or discomfort.With altered sensation, it is easy tomiss the warning signs alerting you to the need to move or roll over sothat you take the pressure offparticular area of your body.


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Poor circulation Some medical conditions like arterialdisease, diabetes, anaemia andoedema (swelling) result in poor bloodcirculation and increase the risk ofpressure ulcers forming in areas suchas the feet and heels. When circulationis poor wounds can take longer to heal.

If you are unable to feel pressureor have poor circulation, it isimportant that you check your skin twice a day. Use a handmirror, or ask your nurse or carerfor assistance if you have difficultydoing this.

Foot careGood foot care is important, particularlyif you have a loss of sensation orchanges in your blood supply to yourfeet from conditions such as diabetes,smoking, arterial disease or stroke.

We suggest that you:

Wash your feet daily with mildsoap, in luke-warm water and dry carefully between the toes.

Examine your feet daily. Use amirror to make sure you see all of the foot. Ask staff to help if youhave difficulty with this inspection.

Keep toenails trimmed with nosharp edges.

Shoes should never need to bebroken in, they should fit properlyfrom the start. Buy shoes in theafternoon when feet are mostswollen.

Check the insides of your shoesfor stones or sharp edges beforewearing them.

Use socks or stockings with a high natural fibre content (cotton or wool) to absorb perspiration.

See a podiatrist if assistance isrequired with toenails, callouses,footwear or general foot care.


10 Correctly fitting shoes

Eat a balanced dietEating properly and maintaining ahealthy weight is important in preventingpressure ulcers. Good nutrition playsa vital role in wound healing by workingfrom the insides out.

Lean meats, poultry, eggs and dairyproducts are good sources of ironand protein, which helps your skinto heal.

Oily fish like tuna, sardines or salmoncontain fish oils that boost thebody’s natural defences and helpfight infection.

Vitamins C and E are important in wound healing so include plentyof fruits, vegetables, wholegrainbreads and cereals in your diet.

If you lose weight quickly or yourappetite is poor for long periods oftime you are at risk of malnutritionand pressure ulcers. Similarly if youare carrying too much weight youmay also be at high risk. In thesesituations you will need to see adietician who will help you improveyour diet.

If you have diabetes aim to keepyour blood sugar levels within therange recommended by yourdoctor, which will contribute tobetter healing.

SmokingSmoking damages blood vesselsand affects overall skin health. It is advisable to stop smoking.Apart from long-term damage,each puff on a cigarette or cigarcauses the blood vessels toconstrict, further reducing theblood flow.


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How to recognise the early warning signsCheck your skin twice a day. Let staffknow if you notice any possible oractual signs of damage immediately. If you are having difficulty checkingyour skin, ask staff to help you or to inspect it for you.

The signs to look for (especially on skin over bony areas) are:

Red / purple / blue skin

Blister

Swelling

Dryness or dry patches

Shiny areas

Cracks, calluses, wrinkles

The signs to feel for are:Hard areas

Warm areas

Swollen skin over bony points

If you find a reddened or suspiciousarea on your skin, change your positionand if the redness is still there after 30 to 45 minutes, try not to sit or liedown on the area for 24 hours.Remember to let staff know if younotice any of these early warning signs.

The best treatment for a pressure ulcer is theremoval of all pressurefrom the location until it heals.


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Remember...

✓ Move, move, move

✓ Look after your skin

✓ Eat a balanced diet

Further information on pressure ulcersAustralian Wound ManagementAssociation at www.awma.com.au

Wound Management Association of Victoria Inc on (03) 9526 6912

Nutrition and dieticiansLook under ‘Dieticians’ in the Yellow pages or have your healthprofessional contact the Nutrition/Dietetics Department of your localhospital for further information.

PodiatristsLook under ‘Podiatrists’ in theYellow pages or have your healthprofessional contact the PodiatryDepartment of your local hospital for further information.

Acknowledgements

This booklet has been collated from a number of resources.

Our thanks to staff at Sir CharlesGairdner Hospital, Nedlands,Western Australia and the NationalInstitute for Clinical Excellence,London, England whose materialprovided the basis for much of this information.

A full reference list of the sourcesused as well as PDF copies of thebooklet can be obtained from theVictorian Quality Council on ourwebsite atwww.health.vic.gov.au/qualitycouncil

Several photographs used in thisbooklet were taken with theassistance of staff from FrankstonHospital, Peninsula Health.

Local information

If you have any queries or want further advice or information speak with your nurse.

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