Pressure ulcers develop when the skin is compressed for an extended period, preventing adequate blood flow. Without enough blood to nourish it, the skin may deteriorate and become sore.
People with a spinal cord injury (SCI) are among the most vulnerable, as 21–36% of them get pressure ulcers due to their inability to move freely. The elderly, especially those over 70 and anyone confined to a wheelchair, are also prone to developing pressure injuries.
Common Areas for Pressure Ulcers
It is common for pressure ulcers to develop where the skin directly sits on bony areas with less tissue to prevent rubbing with the surface. For example,
- Back of head
- Back
- Shoulders
- Elbow
- Back of knees
- Hips
- Buttocks
- Heels
- Ankles
If the patient’s skin is delicate or wet and the surface is hard, bed sores can develop in less than two hours. So it is important to prevent pressure injury, as it is the only easy solution.
Symptoms and Stages of Pressure Ulcers
Pressure ulcers, also called “bed sores,” can be as mild as a little redness on the skin or as bad as damage to the muscles and bones.
The symptoms of pressure ulcers are classified by their severity. Stage I is the least severe stage. Stage IV is the most severe.
Stage 1: An inflamed, excruciating area of skin that does not blanch (turn white) when pressed, suggesting a pressure ulcer may develop. The skin’s surface can be warm or cold, firm or soft.
Stage 2: The skin develops lesions or an open sore. The region surrounding the wound may be red and inflamed.
Stage 3: The skin now develops a crater or ulcer, an open, sunken cavity. There may be visible body tissue in the ulcer.
Stage 4: The pressure ulcer has become so severe that muscle, bone, and sometimes tendons and joints have been damaged.
In most cases, Stage I or II wounds can be healed with proper treatment and wound care. Ulcers in Stages III and IV are more challenging to manage and may take significantly longer to recover.
Why is turning and repositioning important?
One of the most important measures to avoid pressure sores is to lift and turn a bedridden patient or person regularly.
Turning the position often helps relieve pressure and ensure the skin and soft tissues get enough blood, especially in high-risk places like the heels, sacrum, hips, elbows, and head base.
A Manual for Effective Positioning
Positioning the person or patient with the right method is necessary.
Placing a sheet beneath the patient facilitates positioning. A drawsheet is made of a material that slides easily on and off the bed, and a fitted sheet can also be used. Placing of sheet required the following steps,
- Make the bed flat and adjust the bed level to your comfort level.
- Get as near to the patient as you can.
- Place a half-rolled-up slide sheet or draw sheet against the person’s back and turn them to one side.
- Spread the sheet evenly under and roll the patient onto it.
- Make sure the head, shoulders, and hips are on the sheet.
Positioning in Bed Supine
To ensure proper positioning, one must consider the “Rule of 30 Degrees,” also mentioned in the clinical practice guideline.
The Rule of 30 states that the head of the bed should be elevated no more than 30 degrees from the horizontal, and the body should be positioned in a laterally inclined position of 30 degrees.
In the laterally inclined position, tilt the person’s hips and shoulders 30 degrees from the supine position and use cushions or wedges to position the patient without applying pressure to the hips or buttocks.
Once your loved one is in the right position, provide additional comfort and support with pillows under the knees.
Every two hours, gently pull the person and switch positions between lying on the back, right, and left sides.
Side-lying
Most bony markers are relieved of pressure, and the greater trochanter is protected when the patient is in a side-lying posture.
Moving the patient’s lower hand over their head before turning them onto their stomach or side is important. A back pillow to prevent rolling back, one in front to support arms, and one for both lower limbs are placed.
Do not place one leg over the other. Instead, put the top leg forward, and the bottom leg behind to help keep the side-lying position, and put a pillow between the legs for extra support.
Prone position
Prone positioning can help with pressure reduction on the hip and lower back. But it can cause breathing difficulties if not done properly. Pillows can be placed beneath the stomach, one below the chest or shoulders, to support the shins, legs, and feet.
Seated reposition method
People who are seated in wheelchairs must be repositioned more frequently than those who are bedridden.
The best is to shift weight every 15 minutes. If a person cannot, then it is recommended to move after every hour.
Those operating a power wheelchair can use the inclination and recline functions to relieve pressure when seated upright.
One can also use a pressure redistribution cushion to distribute body weight without impeding function or increasing the risk of skin injury.
Bed positioning should be adapted to the specific needs of the patient. For advice, speaking with a physical therapist who can instruct you on performing transfers and maintaining the positioning with care is best.
What else can help with pressure ulcer prevention?
The Clinical Guidelines Committee provides recommendations to treat and prevent pressure ulcers. It includes
Reposition
When in bed, repositioning the body to the opposite side every two hours is essential. Individuals with severe upper-body weakness or complete paralysis will require multiple daily repositionings and pressure relief assistance from a caregiver.
Skin Care
It is essential to keep a check on the skin. Skin in good health is intact, well-lubricated with natural lubricants, and well-nourished with blood. One should adhere to these recommendations.
- Use lukewarm (not boiling) water to clean.
- Avoid aggressively massaging over bony areas of the skin and stick to gentle cleansing agents to reduce the risk of skin irritation.
Elevate the Head
To relieve pressure on the sacrum and lower back, elevating the head of the bed by 30 to 45 degrees may be helpful.
Use Pressure-relieving material/equipment
Pressure-relieving devices such as foam pillows, air-filled beds, and alternating pressure mattresses can help disperse weight and lower the risk of pressure ulcers by providing comfortable support surfaces.
Even when pressure-reducing surfaces are used, it is essential to remember that repositioning is still needed.
Avoid bony prominencies
Avoid putting any part of the body squarely on bony prominences, such as the hips, elbows, and knees, as they are more prone to getting a pressure injury.
The main goal of treating pressure injuries in patients is to stop the ulcer from spreading and damaging the tissue around it.
What Experts Say?
The above video shows how proper positioning and cushioning can help prevent pressure injury in a bedridden individual. It offers the types of equipment that can be used and includes video demonstrations on how to place them.
Another video in which a physical therapist shows how to take a patient from a lying position to a side-lying position for pressure-reducing purposes
Another video in which a physical therapist shows how to take a patient from a lying position to a side-lying position for pressure-reducing purposes
Before you Go
According to clinical practice guidelines, routine skin inspections, cushioning bony skin areas, wound care, maintaining a healthy weight, and daily body repositioning can help prevent pressure sores and improve a person’s quality of life. But losing weight when you can’t walk can be difficult. Read my article here, and use the tips to make it easier.
