Preventing pressure ulcers

What is a pressure ulcer?

Pressure ulcers (also known as a ‘pressure sores’ or ‘bedsore’) are when the skin or the tissues underneath it are damaged. This usually happens to bony parts of the body, such as the heels, elbows, hips and base of the spine. They can also be related to medical or other devices.

Pressure ulcers can happen to anyone, but usually affect people who are spend a lot of time in a bed or who sit in a chair or wheelchair for long periods of time.  They often develop gradually, but can sometimes form in a few hours.

A pressure ulcer can look like aggravated skin or as an open wound. These injuries can be painful.

Symptoms of pressure ulcers

Pressure ulcers are categorised depending on how serious they are.

Early symptoms of a pressure ulcer

• part of the skin becoming discoloured – people with pale skin tend to get red patches, while people with dark skin tend to get purple or blue patches
• discoloured patches not turning white when pressed
• a patch of skin that feels warmer or colder than the skin around it, or may feel spongy or hard
• pain or itchiness in the affected area

A doctor or nurse may call a pressure ulcer at this stage a category 1 pressure ulcer.

More serious symptoms of pressure ulcers

The skin may not be broken at first, but if the pressure ulcer gets worse, it can form:

• an open wound or blister – a category 2 pressure ulcer
• a deep wound that reaches the deeper layers of the skin – a category 3 pressure ulcer
• a very deep wound that may reach the muscle and bone – a category 4 pressure ulcer
• deep tissue damage, where the skin above is intact but the area beneath is injured. These injuries take time but often develop into category 2 to 4 pressure ulcers.

What causes pressure ulcers?

There are 2 ways pressure ulcers can happen.

Firstly, from direct pressure and secondly by a combination of pressure and shear or friction. In both cases the most vulnerable parts of the body are bony areas.

Pressure

A pressure ulcer will usually develop when there is direct pressure from a firm surface to a bony area of your child’s body for a long time. This is because a bony area presses down through the tissue layers against the hard surface, pinching the blood vessels and restricting blood flow, oxygen and nutrients getting to that area.

If the pressure is not relieved regularly the tissues start to break down causing a pressure ulcer to develop.

Shear

When ‘shear’ occurs, the surface of the skin and underlying bone moves in opposite directions. This ‘shear’ movement stretches and tears the internal tissues causing damage. A typical example would be if your child regularly slouches or slips down in bed, so their skin stays in one place, but the bones and tissues underneath move a lot more.

Friction

Friction damage occurs when the skin rubs against a surface, such as a splint. The rubbing action of skin against a surface causes skin stripping where the top layers of your child’s skin are damaged. This leaves damage on the surface of the skin and when coupled with prolonged pressure this can easily turn into a pressure injury.

Who is at risk of pressure ulcers?

Pressure ulcers are usually associated with old people however, anyone can develop a pressure ulcer. Children’s skin is particularly vulnerable to skin damage as it is thinner than adults and still developing.

Consider the following risk factors when caring for your child:

The risk of prolonged pressure to vulnerable parts of the body

• Does your child have restricted movement?
• Can your child change position by themselves?
• Does your child spend long times in bed or a wheelchair?
• Does your child have a medical device or equipment?

Damaged or weakened skin that is more vulnerable to pressure damage

• Is your child unable to control when they pee or poo (incontinent)?
• Does your child sweat a lot?
• Has your child had previous skin damage?

Communication and sensation

If your child cannot tell pressure damage is happening, let you know something is wrong or that they are in pain.

• Is your child unable to communicate?
• Is your child unable to feel parts of their body?

Areas at risk of pressure injury

Other areas at risk of pressure damage are those with medical equipment is attached to the skin, such as:

• Ears, nose, and cheeks – if tubing is present
• Around the face – if oxygen or non-invasive ventilation masks are used
• Arms and legs – especially if in plaster casts, splits or hip spica’s
• Body – tracheostomy sites, feeding tubes, monitoring probes

Preventing pressure ulcers

Assessing risk

In hospital, we use risk assessment tools to measure your child’s risk of pressure damage. This helps us identify children at risk and plan some ways to care for your child that will prevent pressure injuries.  When your child is at home, you should think about these risk factors:

• Lack of movement
• If your child often gets wet, by sweating, peeing themselves or spilling water
• If your child cannot tell you when they are in pain or their skin feels diferent
• If your child has equipment and medical devices touching their skin
• If your child is eating healthily and having enough to drink

Skin inspection and skin care

You can look at your child’s skin inspection whilst you are giving personal care to your child. Look at your child’s skin whilst they are in the bath, shower, during a nappy change or whilst changing their clothing. It is important to check your child’s skin every day as pressure damage can develop quickly.

What to look for?

The first signs of skin damage you may find is usually a red mark. If you find a red mark there is a simple test, called the ‘blanch test’, to see if this mark is the first signs of pressure damage and how serious it is.

The blanch test

Press your finger lightly on the red area and hold for 5 seconds. Then lift your finger away.

Blanchable

If your child’s skin has gone pale (blanched) and then returned to red then this is currently not pressure damage. You should still check if there is moisture there as the redness may be from moisture damage and need treatment to stop it getting worse.

Non-blanchable

If your child’s skin stays red and does not change colour then this is pressure damage. This is a category 1 pressure ulcer.

If your child has darker skin or equipment is covering the skin

You can check for other signs of pressure damage which include :

• pain
• purple colour of the skin
• soft boggy areas
• firmness
• feeling warmer or cooler than surrounding skin

Equipment to reduce pressure damage

We can provide special equipment to reduce your child’s risk of pressure damage which includes:

• Pressure reducing mattresses
• Pressure reducing cushions
• Foot protectors

Equipment that can increase pressure damage

There is a risk that some equipment your child needs when they are unwell could cause pressure damage.

Common equipment that causes pressure damage:

• plaster casts, splints, neck collars and braces
• saturation probes, feeding tubes, intravenous access
• oxygen masks, nasal cannulas, ventilation masks

To help prevent equipment-related pressure damage:

• Frequently relieve equipment from skin where possible
• Frequently repositioning tubing if possible
• Prevent your child from lying or sitting on any tubing if possible

Keep moving

We know prolonged pressure over bony and vulnerable areas of your child’s body can cause a pressure ulcer to develop. Regularly changing your child’s position or getting them to move around, if they are able, will relieve pressure and return blood flow to any areas affected by pressure.

Ideally you should aim to change your child’s position every 2 to 4 hours to relieve pressure areas.

Incontinence and moisture

Moisture associated skin damage, also known as moisture lesions, is caused by the skin being exposed to a source of moisture for a long time. This can cause the skin to become red and sore and can lead to the skin becoming broken down.

The most common form of moisture damage is linked with incontinence (when a child pees or poos themselves). The damage is caused by constant exposure to pee and poo and  this can be very painful for the child and distressing for you as a parent.

Other sources of moisture damage:

• Sweat
• Fluid leaking from an existing wound
• Saliva (spit)
• Mucus or fluid – such as from the nose, peg sites and tracheostomy sites

A good skin care regime is important to keep skin healthy and will help prevent moisture damage. You should avoid soap products as these can irritate fragile skin. Water-based barrier creams prevent damage to the skin from too much moisture.

Eating and drinking

Your child needs a good variety of nutritious foods to stay as healthy as possible. Children need to have enough vitamins, calcium and protein to give them energy to grow, and play. Vitamins from a healthy diet are also important to help children heal, fight infection, illnesses and diseases. They help with brain development, encourage wound healing, and keep skin healthy. If your child has a wound, then getting protein in their diet helps to repair and maintain healthy skin.

What are the risks of your child developing pressure damage?

• Not eating enough (malnutrition) – Not having enough nutrients lead to weak skin and immune system
• Not drinking enough (dehydration) – This causes dry, brittle skin
• Eating unhealthy food (nutritional deficiency) – A bad diet lacks the vitamins to maintain healthy skin.
• Unplanned weight loss – This causes loose, weakened skin
• Being overweight (obesity) – Higher levels of sweat increase the risk of moisture damage and risk of skin damage happening.