Pressure Sores

Pressure sores are more common over areas where your bones are close to your skin (bony prominences), such as your heels, the lower part of your back, and your buttocks. Various things can increase your risk of developing a pressure sore. Risk increases if your mobility is reduced for any reason and you spend long periods lying in bed or sitting in a chair.

There are various measures you can take to prevent most pressure sores from developing. These include changing your position as much as possible and using pressure-relieving devices.

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

Pressure sore symptoms

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

Initial signs may be discomfort, tingling, and itchiness in these areas.

Small areas of the skin change colour, for example, red patches on white skin, and purple or blue on brown or black skin. When you press on this patch, it doesn’t change colour. The skin patch also changes how it feels to touch. The patch may feel warmer, harder, or spongy.

Who is at risk of pressure sores?

Most pressure sores occur in hospital patients. They affect between 1 and 5 in every 100 people admitted to the hospital. However, pressure sores can also develop in individuals at home or in nursing or residential care homes.

A pressure sore 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 stool (faeces). This causes damp skin, which is more easily damaged.
• Have diabetes (this can affect sensation and the ability to feel pain in parts of your 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 poor circulation in your legs or arms, caused by narrowing of your arteries by atheroma (peripheral arterial disease).

What causes pressure sores?

Pressure

Pressure sores are caused by the pressure from the weight of the body pressing down on the skin. They usually occur when a place where bone is close to skin (a bony prominence) is pressed against a surface such as a chair or a bed. This compresses the skin and underlying tissues and can also damage blood vessels. Rubbing (friction) of the skin can also play a part in the formation of a pressure sore.

Sliding layers of skin

Spending long periods in bed or in a chair, people may slide down and need to be pulled back up again by someone else (or they may be able to pull themself back up). However, as these sliding and pulling movements happen, the layers of the skin also slide over each other, as well as over the tissues under the skin. These sliding, or ‘shearing’, forces can also contribute to pressure sore formation. Changes to the skin as it ages may make this sliding of the skin more likely.

Moisture

A lot of moisture around the skin (for example, if there is urinary or stool (faecal) incontinence or sweating a lot) can increase the effects of pressure, friction and shearing forces. Damp skin becomes softer and more fragile. Try to keep the skin clean and dry. Use a moisture barrier cream over the buttocks and pelvic area.

What do pressure sores look like?

Pressure sores initially appear as areas of discoloured skin. If they worsen, the skin may appear as a blister that develops into an ulcer. If pressure sores are not treated, the ulcer can involve deeper layers of the skin, muscle and even expose bone underneath. Pressure sores can develop very quickly. In individuals at high risk, a pressure sore can develop within less than an hour.

Pressure sore stages – Grade 1-4

Pressure sores can appear differently depending on their severity. They are graded based on their severity and the extent to which they penetrate.

• 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 skin is broken (an ulcer), but 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.

Pressure sore treatment

If you already have a pressure sore, it should be assessed by a qualified healthcare professional. They should be able to determine what grade of pressure sore you have, which is a way of categorising the severity of the sore. They will also look for any signs of infection and try to work out what caused the sore.

Healing a pressure sore is a journey in which you play a significant role. To aid this process, it’s essential to adjust your position as much as possible and utilise pressure-relieving mattresses and cushions. These are not just aids, but tools that empower you to relieve the pressure on the pressure sore and contribute to your healing.

Seating

When it comes to pressure sores on the buttocks, seating and posture are key factors in preventing them. It’s essential to recognise that the use of pressure cushions alone will not facilitate the healing of a pressure sore if posture is not assessed correctly and the underlying cause of the pressure sore is not identified. Chairs that are the wrong size or not adaptable to posture and positioning pose a significant risk of developing pressure damage. Being aware of these factors puts you in a better position to manage your condition, and staying cautious about your seating choices is crucial.

Mattresses

Current recommendations suggest that individuals with pressure sores should use a high-specification foam mattress. This type of mattress is designed to provide better support and reduce pressure on the body. If you use a wheelchair or sit for prolonged periods, it’s important to use a high-specification foam or equivalent pressure-redistributing cushion. These cushions are specifically designed to redistribute your body weight, reducing the risk of developing pressure sores that can result from prolonged sitting.

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

• Pain relief – a pressure sore 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 sore.
• Dressings – various dressings may be used, including gel and foam-based dressings and keeping the wound clean with mild soap and water.
• Antibiotics – these may be needed if there are any signs of infection.
• Surgery – sometimes surgery is needed to remove damaged or dead tissue or skin. The medical term that is used for this type of surgery is ‘debridement’. Sometimes, plastic surgery may be used to close a pressure sore that is not healing. Skin grafts may be needed.

Pressure sore prevention

Change 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 at least every 15 minutes 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 to move or have help with a position change, and what position should be moved to.
• How to support the feet.
• How to maintain a good posture (for example, how to stop the body slipping down in a chair).

Eat and drink the right things

You must eat a balanced diet and ensure you don’t become deficient in any nutrients or vitamins. Drink plenty of fluids to help prevent pressure sores.

Use pressure-relieving devices

There are various devices available that can help relieve pressure and prevent pressure sores. They include special beds, mattresses, mattress pads and cushions. It’s crucial to consider all the surfaces that the at-risk person sits or lies on for pressure-relieving devices.

Mattress pads lie on top of the mattress to help decrease pressure on the skin. They can help prevent sores in individuals who spend most of their time in bed.

Make regular checks of the skin

You or your carer should check your skin regularly and report any concerns to your healthcare professional immediately.

What is the outlook for pressure sores?

The outlook (prognosis) for pressure sores is usually good if they are treated before they reach an advanced stage and before any complications develop. The outcome can be much worse for advanced stages of pressure sores that aren’t treated early enough. The outcome will also depend on where the pressure sore is on the body, their general well-being and how well they respond to the treatments. If someone has a pressure sore, they’re more likely to develop another pressure sore in the future.