What is a pressure ulcer?
A pressure ulcer occurs when an area of skin and the tissues underneath are damaged by being under constant pressure that reduces blood supply. This leads to a lack of oxygen and nutrients, causing tissue damage and ultimately the development of a wound. They tend to happen when people spend long periods in a bed or chair, which is why changing position to reduce or remove the pressure on a particular area can be key to prevention. Moisture is also a contributing factor skin breakdown, incontinence, sweating, and a weeping wound (if not addressed) may cause pressure ulcers.
Pressure ulcers can also be caused by shear and friction. Shear happens when layers of skin are forced to slide over one another, deeper tissues or bony structures, for example spine or pelvis, causing damage beneath the skin which can then develop into pressure ulcers. Slouching while sitting in a chair, for example, is a common cause of shear. It is therefore important that the client’s chair is well designed for their particular needs and that they maintain a good posture while seated.
They need to choose a good fitting seat that’s comfortable. If the seat is too large their shoulders won’t be supported causing them to lean, if it’s too small, the gap will put pressure on their hips. Make sure the seat depth is good for them, too, with their calves gently touching the leg rest.
Prevention is better than cure
When it comes to pressure ulcers, prevention is always better than cure. As occupational therapists, we consider all the support surfaces throughout the 24-hour period, as well as any causative factors and environmental limitations.
Here’s our essential guide to help minimise the risk in your care setting.
Risk assess your clients
Firstly, complete a risk assessment. You should have a moving and handling plan in place for each individual. Specific assessments for pressure ulcer risk should be ongoing and reviewed at any point when the client’s risk factors, abilities or care needs change.
Make sure they understand the risk
It is also important to explain to your client, as well as their carers, family, and friends, the importance of changing position regularly and how it can help reduce the risk of pressure ulcers. Develop a practical and realistic positioning plan with the client and their carers, always taking their needs, routines, and lifestyle choices into account.
Change your client’s positions regularly
The best prevention against pressure ulcers is moving, repositioning, even small movements can help reduce the risks of skin damage.
For clients at high risk of pressure ulcers, those who are unable to move, or are in one position for long periods of time a ‘repositioning timetable’ or risk assessment plan should be drawn up to make sure their position is changed regularly to relieve the pressure on skin and to help prevent sores and ulcers from forming.
According to NICE guidelines* repositioning is recommended every 6 hours for people at risk of developing pressure ulcers and every 4 hours for people at high risk, or as often as once every 15 minutes to avoid constant pressure on a particular part of the body. However, this will vary from person to person as it would depend on other factors, such as their skin condition, environment, and their overall health. A risk assessment plan will outline any problem areas and state how and when a person should be repositioned. This should include correct sitting and lying positions, adjusting those positions, support for feet to relieve heel pressure, and any special equipment they may need.
Equipment is available to help reposition someone who is unable to do this for themselves. Mobile hoists and slings can help to support and facilitate easier position changes and enable transfers when moving from bed to a chair or wheelchair, you may also find a slide sheet can be an additional help when moving a person.
Minimise skin injury when repositioning
Identify the most appropriate method for repositioning the client to minimise skin injury, avoiding friction and shearing movements, for example, using equipment to enable transfers such as transfer boards, bed rails, slide sheets. You may want to consider the Parafricta range to help with this. It’s designed to address the shear and friction which can contribute to skin damage. The Parafricta products, which include bootees, undergarments, and bedding, are made of a silk-like material that is specially woven to reduce skin breakdown for people who are at risk. It’s worth keeping in mind that although this range has had promising results**, more evidence for their effectiveness in clinical practice is needed to support the case for routine adoption of Parafricta bootees and undergarments in the NHS.
Choose the right moving and handling equipment
A wide variety of moving and handling equipment is available, such as hoists, stand aids handling belts. Hoists can be mobile, gantry style or fixed to the celling. Stand aids offer support to those who have some mobility. When selecting this type of equipment, it’s important to accurately assess what is best suited to a particular need for the client. This will ensure that the equipment you choose is compatible, safe for both the carer and the person who needs to be moved in the environment to be used in.