What is a pressure ulcer?

It is a localised injury to the skin and/or underlying tissue usually over a bony area as a result of pressure can also be in combination with shear. (EUPAP, 2009).

You can find some typical pictures of different category skin ulcers above.

Here are five simple steps to remember to help prevent pressure ulcers.

Remember SSKIN:

● surface
● skin
● keep moving
● incontinence/moisture
● nutrition and hydration.

Surface

• Change position regularly to prevent pressure ulcers and reduce pressure on existing ones.
• Use pressure-relieving equipment, such as mattresses and cushions, ensuring proper function and connection to pumps.
• Minimise layers between the patient and pressure-relieving surfaces.
• Ensure cushions are the correct size for the chair to maintain stability and protect skin integrity.
• Check if footwear is appropriate and properly fitted.
• Assess the patient’s mobility and determine if assistance is needed.
• Consider any physical limitations affecting sitting ability, such as balance issues or joint deformities.

Positioning

When helping a person sit, ensure they are in the correct position—upright with feet flat on the ground, not leaning or slouching. Patients with vulnerable areas should not sit for long periods and should get bed rest.

Use slide sheets under the person to move them up the bed if they can't do it themselves or other methods aren't suitable. Bed sheets alone are not acceptable for moving.

Take care when positioning and removing slide sheets. For heavy legs, use slide sheets to avoid dragging. A roller slide sheet or folded flat sheet under the heels helps prevent heel drag when hoisting.

Position a slide sheet behind the upper body before raising someone into a sitting position on a profiling bed to reduce friction. Regular repositioning helps prevent pressure ulcers, and equipment like standing hoists can reduce sitting time.

Ensure the hoist sling is correctly fitted and appropriate for the task. Consider using slide sheets to assist with positioning the sling.

Skin inspection

Common areas where pressure ulcers can develop:
● shoulders or shoulder blades
● elbows
● head
● ears
● knees, ankles, heels or toes - if these areas are black leave dry and urgently refer to podiatry to assess, also inform a qualified health care professional
● spine
● coccyx (tail bone at
the bottom of the spine)
● buttocks
● hips
● heels – you can offload the pressure on the heels by floating them off the end of a pillow underneath the calves
● always ensure you are changing the patient’s position even on pressure relieving equipment.

What’s the difference between pressure and moisture?

Blanching erythema is when you press an area of decolouration and the area goes white and returns back to the original colour.

Non blanching erythema is when you do the above but you have no colour change at all when finger pressure is applied.

Keep your patient moving

• Mobility – reduced or restricted ensure you enable or help the patient move and change position frequently.
• Mental health conditions (schizophrenia or depression) can lead to reduce motivation and willingness to move which will vary with fluctuations in their condition.
• Document each time that you help to alter their position; a repositioning chart may be helpful.
• High pressures over bony prominences for a short period lead to low pressures over a long period.

Incontinence and excess moisture

Those suffering from incontinence are at a greater risk of skin breakdown.

The presence of urine or faeces creates moist environment leading to softening of the skin which can cause skin breakdown.

Look out for:

• incontinence/excessive sweating
• excessive sweating or incontinence.
• frequent washing of skin with soap and water as this can remove skins natural oils and lead to dryness.

Washing the skin is an ideal opportunity to inspect for skin problems.

Try using barrier creams to help protect vulnerable skin.

Nutrition and hydration

If your patient is experiencing poor appetite or unplanned weight change, check weight where possible and alert a health care professional.

You could help follow up on actions agreed in the care plan – for example help encourage and record food and fluid intake
and ensure food fortification.

Tips of how your patients can increase their dietary intake:

● eat little and often.
● keep nutritious snacks readily available.
● add extra calories to meals e.g. adding butter, cream,
grated cheese, extra sauces and gravy.
● eat puddings twice a day and have nourishing drinks.
● allow time to eat slowly and encourage chewing food well.
● keep some cupboard essentials on standby for meals and snacks
e.g. tins of soup/beans/crackers/UHT milk.
● drink at least six to eight mugs/glasses of fluid per day.
● for people with diabetes and a poor appetite, it is important that the advice above is followed, however if blood glucose levels appear erratic, a diabetes medication review will be needed.