Education
Pressure ulcers – risk factors and steps for prevention

People living with spinal cord injuries are at greatest risk of pressure ulcers, because the nerve damage from these injuries is often permanent and compression of skin and other tissues is ongoing. However anyone who is immobilized by acute illness, injury or sedation — even for a short time following an operation or accident — can develop pressure sores.

There are a number of factors that increase the risk of pressure sores in patients unable to move, such as old age and poor hygiene. We review each of these risk factors below followed by some general steps for prevention.

THE RISK FACTORS

Age
The majority of pressure sores occur in people older than 70. Older adults tend to have thinner skin than younger people do, making them more susceptible to damage from minor pressure. They're also more likely to be underweight, with less natural cushioning over their bones. And poor nutrition, a serious problem among older adults, not only affects the integrity of the skin and blood vessels but also hinders wound healing. Even with optimum nutrition and good overall health, wounds tend to heal more slowly as you age, simply because the repair rate of your cells declines.

Nursing home or hospital patient
In general, nursing home residents have higher rates of pressure ulcers than people who are hospitalized or cared for at home, perhaps because they are often especially frail and/or nursing staff are limited. Rates are also high for hospitalized patients who are immobilized, such as people who are recovering from a hip fracture or who are in a coma.

Decreased sensory perception
Usually, an increase in pressure on tissue will cause a response, and a person will adjust their position accordingly. A loss of sensation, due to stroke, spinal cord injuries or other neurological disorders, decreases a person’s ability to feel the signals and means they are unaware that a pressure ulcer is forming. Sedative drugs can also limit sensory perception.

Natural thinness or weight loss
You often lose weight when sick or hospitalized, and muscle atrophy and wasting are common in people living with paralysis. In either case, you lose fat and muscle that help cushion your bones. Some experts say the best way to prevent skin breakdown is to have at least two inches of muscle over bony areas.

Malnutrition
Poor nutrition affects the entire body. Healthy eating means healthier skin and circulation. You're more likely to develop pressure sores if you have a poor diet, especially one deficient in protein, zinc and vitamin C. You're also more likely to have recurrent pressure sores, more severe infections and slower healing wounds than are people with healthier diets. Dehydration is also associated with an increased risk of ulcers.

Urinary or fecal incontinence
Urinary or fecal incontinence increases the moisture that collects around the areas that are already at highest risk – the lower back and hips. Problems with bladder control can greatly increase your risk of pressure sores because your skin stays moist, making it more likely to break down. The moisture provides friction, and the lack of hygiene also further irritates the skin. And bacteria from fecal matter not only can cause serious local infections but also lead to life-threatening systemic complications.

Other medical conditions
Because certain health problems such as diabetes and vascular disease affect circulation, parts of your body may not receive adequate blood flow, increasing your risk of tissue damage. And if you have muscle spasms (spastic paralysis) or contracted joints, you're subject to repeated trauma from friction and shear forces.

Smoking
Smokers have a higher incidence of pressure sores than nonsmokers do. They also tend to develop more severe wounds and to heal more slowly, mainly because nicotine impairs circulation and reduces the amount of oxygen in your blood. The risk increases with the number of years and cigarettes smoked.

Decreased mental awareness
People whose mental awareness is lessened by disease, trauma or medications are often less able to take the actions needed to prevent or care for pressure sores.
STEPS FOR PREVENTION

Steps for prevention are based on research, professional judgment and practice. These steps can also keep pressure ulcers from getting worse. Some steps apply to all prevention efforts while others apply only in specific conditions.
Please note, none of these steps are surefire ways to prevent pressure ulcers. If the prevention of pressure ulcers interferes with more important treatment measures, then the overall health and comfort of the patient should be the primary concern and latter measures should take precedence. You should consult your healthcare professional for advice in what’s right for reducing your risk of pressure ulcers.

Step 1 – Take care of your skin
You or your caregiver should inspect skin at least once a day to identify problem areas before they become serious. The goal is to find and correct problems before pressure ulcers form. Pay special attention to pressure points (see our article Pressure Ulcers – a clinical insight for further details) and reddened areas that do not fade after you change position. You can use a mirror for hard-to-see areas.

Clean skin as soon as it is soiled. Use a soft cloth or sponge to reduce friction and/or injury to skin. Take a bath when needed for comfort or cleanliness. If bathing daily, additional measures should be taken to minimize irritation and prevent dry skin. Bathe with warm (not hot) water and mild soap. Avoid moisturizers or soap with alcohol.
Keep skin moist with cream or oil, but minimize moisture from wounds, urine, stool or sweat. Avoid cold or dry air.
When moisture cannot be controlled, use pads or briefs that absorb urine and have a quick drying surface that keeps moisture away from the skin. You can also use special ointments to protect skin from unwanted moisture. A thin layer of cornstarch can reduce friction damage

Step 2 – Protect your skin from injury
Avoid massage of your skin over bony parts of the body. Massage may squeeze and damage the tissue under the skin and make you more likely to get pressure ulcers.
Limit pressure over bony parts by changing positions or having your caregiver change your position.

  • if in bed, your position should be changed at least every 2 hours
  • if in a chair, your position should be changed at least every hour (if able to shift your own weight, do so every 15 minutes while sitting)

Reduce friction (rubbing) by making sure you are lifted, rather than dragged, during repositioning. Friction can rub off the top layer of skin and damage blood vessels under the skin. You may be able to help by holding on to a trapeze hanging from an overhead frame. If nurses or others are helping to lift you, bed sheets or lifters can be used. A thin film of cornstarch can be used on the skin to help reduce damage from friction.

Avoid use of donut-shape (ring) cushions, which can increase your risk of getting a pressure ulcer by reducing blood flow and causing tissue to swell.

Step 3 – Eat well for balanced nutrition
Eat a balanced diet if at all possible. Protein and calories are very important for healthy skin, which is less likely to be damaged.

If you are unable to eat a normal diet, talk to your healthcare provider about nutritional supplements.

Step 4 – Improve your ability to move
A rehabilitation program can help some persons regain movement and independence. Communicate with your healthcare provider about your needs, wants and concerns. Your participation in maintaining your comfort is crucial.

Step 5 – Maximize mobility and minimize risk

If bed bound:

  • A special air mattress helps to prevent pressure ulcers; talk to your healthcare provider about the best option for you.
  • The head of the bed should be raised as little and for as short a time as possible if consistent with medical conditions and other restrictions. When the head of the bed is raised more than 30 degrees, your skin may slide over the bed surface, damaging skin and tiny blood vessels.
  • Pillows or wedges should be used to keep knees or ankles from touching each other.
  • Avoid lying directly on your hipbone (trochanter) when lying on your side. Also, a position that spreads weight and pressure more evenly should be chosen -- pillows may also help.
  • If you are completely immobile, pillows should be put under your legs from midcalf to ankle to keep heels off the bed. Never place pillows behind the knee.

If chair bound:

  • Foam, gel, or air cushions should be used to relieve pressure; talk to your healthcare provider about the best option for you
  • Avoid donut-shaped cushions. They reduce blood flow and cause tissue to swell, which increases risk of developing pressure ulcers.
  • If you can change positions without help, try to do so every 15 minutes. If not, change position every hour. The increased frequency is necessary because sitting places more pressure on the skin than lying in a bed does.
  • If you cannot change position yourself, make sure your caregiver uses lifting devices instead of dragging you to change your position. Dragging causes friction that can injure skin.
  • Maintain good posture and comfort.