Pressure ulcers – guide for professionals

This quick reference guide is for professionals working with people who may be prone to or whom you suspect may have a pressure ulcer.

What is a pressure ulcer?

“ A pressure ulcer is localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or open ulcer and maybe painful.”  NHS Improvement 2018

Pressure ulcers (also known as pressure sores or bed sores) are areas of damage to the skin and the tissue underneath. There is a higher chance of a person getting a pressure ulcer if they have difficulty moving.

Pressure ulcers usually form on bony parts of the body, such as the heels, elbows, hips and tailbone. They usually develop gradually, but can sometimes appear over a few hours. A pressure ulcer can become a blister or open wound. If left untreated they can get worse and eventually reach deeper layers of skin or muscle and bone.

How are pressure ulcers caused and who is at risk?

Pressure ulcers are caused by something putting pressure on or rubbing the skin (shearing).

Anyone can develop a pressure ulcer, but its more likely if someone has problems moving, as this can mean the weight of their body is always putting pressure on the same areas of skin, which can damage it. People have a higher chance of getting a pressure ulcer if they:

• are over 70 years old
• have problems moving or are confined to bed
• are incontinent
• have had a pressure ulcer before
• have been seriously ill in intensive care or have recently had surgery
• have poor diet or fluid intake, are underweight, or obese
• have swollen, sweaty or broken skin
• have poor circulation or fragile skin
• have problems feeling sensation or pain.

What are the symptoms of a pressure ulcer?

Early symptoms of a pressure ulcer include:

• 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 warm, spongy, or hard
• pain or itchiness in the affected area.

Later symptoms include:

• an open ulcer or blister
• a deep ulcer that reaches the deeper layers of the skin
• a very deep ulcer that may reach muscle, bone or tendon.

What to do if you identify early skin changes

If you are looking after someone either in a care setting or their own home and you identify any early skin changes, it is important that you take action to prevent further deterioration:

• reduce pressure on the skin by offloading the area using the techniques in these illustrations:

• reposition the person more frequently and ensure this is clearly documented
• reduce the risk of rubbing (shearing) by using full length slide sheets when moving and handling the person
• ensure bedding is crease free, clothing does not have thick seams and footwear fits well
• inform the senior member on duty and refer to the district nursing team for support and reassessment / equipment review

When to get medical advice

You must get medical advice immediately if:

• there is red, hot, swollen skin
• pus is leaking from the pressure ulcer
• the person experiences severe or worsening pain, and/or
• they have a high temperature.

These symptoms could indicate that there is a serious infection that needs treatment.

Incontinence and pressure ulcers

If the skin is in contact with moisture for a prolonged period – including sweat, wound leakage, urine or faeces – it becomes more vulnerable to pressure and rubbing (friction/shear) and damage can occur.

Urea in urine and enzymes in faeces alter the ph of the skin, encouraging bacteria so it is particularly important to keep skin clean, dry and moisturised:

• cleanse skin regularly, avoid soap
• use appropriate continence products
• regularly apply moisturiser/barrier cream
• evaluate skin condition at each contact.