Pressure Ulcers

A pressure ulcer (also known as 'bed sores', 'pressure sores' and 'decubitus ulcers') is an ulcerated area of skin caused by irritation and continuous pressure on part of the body. Pressure ulcers are more common over bony prominences (places where your bones are close to your skin) such as your heels, the lower part of your back and your bottom. There are various things that can increase your risk of developing a pressure ulcer - in particular, if your mobility is reduced for some reason and you are spending long periods lying in bed or sitting in a chair. Using the correct preventative measures should mean that most pressure ulcers are avoidable. These include changing your position as much as possible and pressure-relieving devices.

What is a pressure ulcer?

A pressure ulcer is an ulcerated area of skin caused by irritation and continuous pressure on part of the body. It starts as an area of skin damage. The damage can then spread to the tissues underlying the skin. In severe cases, there can be permanent damage to muscle or bone underneath the skin. Pressure ulcers can be very painful and can take a very long time to heal.

Pressure ulcers can affect any area of the body but are more common over bony prominences (places where your bones are close to your skin). Common areas for pressure ulcers to occur are around your sacrum (the lower part of the backbone), your heels, your elbows, your hips, your back, your bottom, the back of your head and your shoulders.

Pressure ulcers can develop very quickly. In people who are at high risk (see below), it can take less than an hour for a pressure ulcer to develop.

What causes pressure ulcers?

Pressure ulcers are caused by the pressure from the weight of your body pressing down on your skin. They usually occur when a bony prominence is pressed against a surface such as a chair or a bed. This compresses the skin and the underlying tissues and can also damage blood vessels. Friction (rubbing) of your skin can also play a part in the formation of a pressure ulcer. Friction can happen, for example, if you are dragged across a surface such as a bed.

If you are spending long periods in bed or in a chair, you may slide down and need to be pulled back up again by someone else (or you may be able to pull yourself back up). However, as these sliding and pulling movements happen, the layers of your skin also slide over each other, as well as over the underlying tissues. These sliding or 'shearing' forces can also contribute to pressure ulcer formation. Changes to the skin as it ages may make this sliding of the skin more likely.

A lot of moisture around the skin (for example, if you have urinary or faecal incontinence or you are sweating a lot) can increase the effects of pressure, friction and shearing forces. Damp skin becomes softer and more fragile.

Using the correct preventative measures (see below) should mean that most pressure ulcers are avoidable.

Who gets pressure ulcers?

Most pressure ulcers occur when someone is admitted to hospital. They affect between 1 to 5 in every 100 people admitted to hospital. However, pressure ulcers can also develop in someone at home, or in a nursing or residential home.

A pressure ulcer is more likely to develop if you:

  • Are seriously ill (including someone in an intensive care unit).
  • Are not very mobile (for example, you may be confined to a chair or a bed), particularly if you are not able to change your position without help from someone else.
  • Have had a spinal cord injury (this means you are unable to move or feel your legs, and sometimes your arms).
  • Have a poor diet.
  • Are wearing a prosthesis (for example, an artificial limb), a body brace or a plaster cast.
  • Are a smoker.
  • Are incontinent of urine or faeces (this causes damp skin which is more easily damaged).
  • Have diabetes (this can affect sensation and ability to feel pain over parts of the body).
  • Have chronic obstructive pulmonary disease (COPD) or heart failure.
  • Have Alzheimer's disease, Parkinson's disease or rheumatoid arthritis.
  • Have recently had a broken hip or undergone hip surgery.
  • Have peripheral vascular disease (poor circulation in your legs or arms, caused by narrowing of your arteries by atheroma).

What do pressure ulcers look like?

Pressure ulcers can look different depending on how severe they are. They are graded depending on their severity and how deep they go:

  • Grade 1 - your skin is permanently red but is not broken at all. It may feel warm, hard or slightly swollen. In dark-skinned people, your skin may be purple or blue in colour.
  • Grade 2 - the ulcer is still superficial. It may look like a blister or abrasion.
  • Grade 3 - the ulcer goes through the full thickness of the skin and there is damage to the tissues underneath the skin.
  • Grade 4 - this is the most severe form. The ulcer is deep and there is damage to muscle or bone underneath.

For pictures of pressure ulcers, see http://www.dermis.net/dermisroot/en/37040/diagnose.htm

Preventing pressure ulcers

The National Institute for Health and Clinical Excellence (NICE) has produced guidelines with recommendations for best practice for the prevention of pressure ulcers. NICE recommends that all people who are admitted to hospital, a nursing home or similar, or people who are receiving nursing care at home, should be assessed for their risk of developing a pressure ulcer. This is usually done by a healthcare professional (usually a nurse). This assessment should be reviewed regularly because your situation may change.

There are various pressure ulcer risk assessment scales that may be used, looking at factors such as your diet, your mobility, your continence, your consciousness level, any underlying illnesses that you may have, etc.

If you are assessed and found to be at increased risk then one or more of the following may be suggested:

1. Change your position as much as possible

Ideally, you should get up and move around as much as possible. However, if this is not feasible, you should change your position as much as possible when you are sitting or lying in bed. You may need help from someone else to change your position. Changing your position means that you are relieving pressure on areas of your body that may be prone to developing pressure sores. Ask your healthcare professional for advice about:

  • How to sit or lie.
  • How often you should move or have help with your position change and what position you should move to.
  • How to support your feet.
  • How to maintain a good posture (for example, how to stop your body slipping down in a chair).

2. Make sure you eat and drink the right things

It is important that you are eating a balanced diet and drinking plenty of fluids to help prevent pressure ulcers. Your healthcare professional may discuss your diet with you to see if it is likely that you are lacking in any nutrients. They may refer you to a dietician and/or you may be advised to take some supplements.

3. Use pressure-relieving devices

There are various devices that are available that can help to relieve pressure and prevent pressure ulcers. They include special beds, mattresses, cushions and overlays (these are placed on top of a mattress). They work either by spreading out the pressure (for example, by moulding around the body) or by regularly removing pressure from different parts of the body (these are the more 'high-tech' devices). All the surfaces that you sit or lie on need to be considered for pressure-relieving devices. This includes chairs and beds.

4. Make regular checks of your skin

Your healthcare professional should check your skin regularly to look for any signs of a pressure ulcer. You or your carer may also be able to check your skin (this may sometimes need the help of a mirror). Tell your healthcare professional if there are any areas of your skin that you are worried about.

Treatment of pressure ulcers

If you already have a pressure ulcer, it should be assessed by a qualified healthcare professional. They may want to take a tracing or a photograph of the ulcer. This can then be used to monitor your response to treatment. They should be able to determine what grade of pressure ulcer you have, look for any signs of infection and try to work out what caused the ulcer.

For a pressure ulcer to heal, you need to change your position as much as possible (as described above) and also to use pressure-relieving mattresses and cushions. These both help to relieve the pressure on the ulcer. Current recommendations are that someone with a Grade 1-2 pressure ulcer should have a high-specification foam mattress or cushion with pressure-reducing properties. Someone with a Grade 3-4 pressure ulcer should have a high-specification foam mattress with an alternating pressure overlay, or a sophisticated continuous low-pressure system.

Other treatments are often needed for pressure ulcers. These may include:

  • Pain relief - a pressure ulcer can be painful. Simple painkillers like paracetamol may be helpful. Sometimes stronger painkillers are needed.
  • A change to your diet - a poor diet can slow the healing of a pressure ulcer.
  • Dressings - various different dressings may be used, including gel and foam-based dressings.
  • Antibiotics - these may be needed if there are any signs of infection.
  • Surgery - sometimes surgery is needed to remove damaged or dead skin. The medical term that is used for this type of surgery is 'debridement'. Sometimes plastic surgery may be used to close a pressure ulcer that is not healing. Skin grafts may be needed.

Are there any complications of pressure ulcers?

A pressure ulcer can become infected. Rarely, this infection can spread to the blood (causing septicaemia or 'blood poisoning') or it can spread to the bone underneath the pressure sore (causing osteomyelitis). In severe cases, a pressure ulcer can cause permanent damage or loss of muscle or bone underneath the affected area of skin. Someone who has had a pressure sore before is more likely to develop a pressure sore in the future.