Fact sheet: Preventing pressure sores

Spending a lot of time in a sitting or lying position is unavoidable for many people. But if you hardly move or do not move at all for long periods of time, your risk of getting a pressure sore increases. A pressure sore is an open wound caused by pressure on the skin. These wounds can be very painful and they only heal slowly. Once you have had one, even if it has healed, it could return. So it is very important to prevent pressure sores from developing in the first place.

If you or someone you are looking after has to lie or sit still, even if it is just for a few days, you need to keep the pressure off the parts of the body that are most at risk. Changing position or turning regularly is very important. The type of surface you are lying or sitting on can also make a difference (such as a special mattress or an overlay like a sheepskin). You also need to keep an eye on possible problem spots so you can react quickly if there are signs of a pressure sore developing.

What are pressure sores and why do they develop?

A pressure sore (also called pressure ulcer, decubitus ulcer or bed sore) is an open wound. It is caused by continuous pressure on the skin, usually because people have been lying or sitting in the same position for a long time. These sores nearly always occur on areas of the body where bone is right under the skin. These places include the tailbone, heels, hips, shoulder blades, ankles, elbows, ears and the back of the head.

 

 

When there is pressure on these areas of skin, the blood supply is restricted and the skin tissue cannot get enough oxygen and nutrients. As a result, the skin gets thinner and may even start to die after some time. This can lead to an open wound, which can be very painful, especially if you lie or sit on it. Open wounds also make it easier for germs to enter the body. That can lead to infections and, if the germs spread, even sepsis (blood poisoning).

How can you tell if it is a pressure sore?

The following classification system is currently the most common way to describe the severity of a pressure sore:

• Stage 1: The skin is red and the redness does not go away after pressure is relieved. It may be warmer than usual, but it is still intact.
• Stage 2: The surface of the skin is damaged, and looks blistered or grazed.
• Stage 3: All of the layers of skin are damaged, resulting in a deep wound that may go as deep as the muscle layers. Parts of the skin may be dead (necrosis).
• Stage 4: A large area of tissue is damaged and dead. Muscles and bones may be affected.

Some people are able to regularly check for signs of pressure sores themselves, for instance using a mirror. If they have been immobile (have not been able to move much, if at all) for a long time, they often get to know the warning signs very well. But many people need help, particularly because pressure sores usually develop on the back of the body.

Skin irritation or damage is not always a sign of a pressure sore. A doctor or nurse can help you assess any suspected problems.

What are the risk factors?

The main cause of pressure sores is lying or sitting in one position for a long time. Most people move all the time, consciously or subconsciously, even when sitting for a long time or sleeping. But people who are very weak, ill, paralyzed or unconscious, move less, or may not move at all. This means that the parts of their body that they are sitting or lying on are exposed to constant pressure. The amount of time it takes for a pressure sore to develop depends on the individual person and his or her situation. Some people get pressure sores overnight, whereas others can lie in one position for several days without any problems.

Healthy people notice pain quickly when there is too much pressure on one part of their body. Some medical conditions can disturb this sensation of pain. For example, people with paralysis often do not feel any pressure or pain in the affected areas of their body anymore.

People who have long-standing diabetes sometimes have limited sensation of pain, too. They may not notice that there is too much pressure on one part of their body. If they also have circulation problems due to conditions like atherosclerosis or blocked arteries, the blood supply to the affected areas is even more restricted, so pressure sores are even more likely to develop.

Malnutrition is a further risk factor in people who are confined to bed. Someone who has very little padding from body fat and does not eat or drink very much will have thinner skin with a poorer supply of oxygen and nutrients. This also means that the skin might be less able to withstand pressure.

Rubbing and shearing (when different layers of skin rub against each other) might also increase wear on the skin. For example, when people are turned in bed their skin may rub against the sheets, leading to red areas and superficial skin damage. So it is important to avoid rubbing and shearing while changing the person’s position. There are various techniques that carers can learn to help reduce the likelihood of this happening.

Skin that is moist from urine, feces or sweat for long periods of time is more prone to damage and irritation. Incontinence alone does not cause pressure sores, but wearing wet or soiled garments for too long can make skin soft and more susceptible to damage. Moreover, good skin care and personal hygiene are important, regardless of pressure sore risk.

How can pressure sores be prevented?

Even if you need to stay in bed or a chair, it does not mean that you cannot move at all. As soon as you are able to walk a few steps or leave the bed and sit on a chair with a bit of help, you should try to do so as often as possible. It is important to keep in mind that sitting on a chair puts more pressure on your buttocks than lying down does. So thinking about what areas of your body are exposed to the most pressure in different positions might help you decide what changes would be a good idea for you. If you use a wheelchair, learning how to relieve pressure is a very important habit to learn and keep up.

The main way to prevent pressure sores is by relieving pressure on the skin: people who are at increased risk of getting a pressure sore need to change position regularly themselves or get some help to do so. How often you need to change position depends on your individual situation. Some people can spend a longer amount of time in one position without getting sore skin, whereas others will have to change position very often.

People who use wheelchairs or need to stay in bed for a long time often say that they realize that a particular spot is starting to get sore, but they sometimes ignore it and hope it will go away by itself. It is important to pay attention and then get some help if you notice a problem might be developing.

Some people who are inactive also say that one of the biggest problems is that they lose their appetite. But you need to stay well-nourished so you need to keep paying attention to your diet. We do not know yet for certain whether or not dietary supplements are useful for preventing pressure sores. But if research is published that can answer this question, we will inform you about it.

Can pressure-relieving surfaces help prevent pressure sores?

Various pressure-relieving support surfaces can lower the risk of getting a pressure sore. Nowadays a lot of different overlays and systems are used in hospitals, nursing homes and at home. These include special foam mattresses which spread the pressure out so that it is not all concentrated on particularly vulnerable areas of the body.

Alternating pressure mattresses are also often used and might help prevent pressure sores. These mattresses consist of several air-filled chambers that are separately inflated automatically with more or less air. The pressure usually changes several times every hour. In this way the pressure on the respective areas of the body is decreased alternately.

Very soft surfaces can make it difficult to move for some people. Because they sink into the surface, it can be hard for them to prop themselves up and change positions, for example. People who are weak but would normally still be able to change positions on their own may move less when lying in bed because of this. It can therefore make sense to take these differences into account and to check exactly whether another mattress or overlay is needed.

Sheepskin overlays are a further option. Research on special Australian medical sheepskins has shown that they can prevent pressure sores from developing. However, other types of skins have not been tested in this way.

You can read more about the research on mattresses, overlays and other surfaces to prevent pressure sores here.

What can your relatives do to help and how can you stay as independent as possible?

Carers may do things for people who are in bed, such as turning them over, even though they might actually still be able do it themselves – or with very little help. Remaining as mobile as you can is the best way to prevent pressure sores. For example, you could agree on certain times of the day when your carer could take a few steps with you. Sitting on a chair to eat is also an important opportunity to ensure some movement.

Whether you are looking after someone at home, or visiting them in hospital or a nursing home, even these small movements such as taking a few steps and getting to the table to eat could really help.

If you have to stay in bed for a long time, a care plan is usually drawn up with the carers. The plan may include how often you need to change position every day. It is important to make sure that these plans are actually put into action, even though it can be dreary and difficult. Keeping an eye on vulnerable parts of the body to detect early signs of a pressure sore developing is crucial. Relatives can attend special training courses to learn how best to turn and reposition their loved ones. In Germany, health or long-term care insurance will often cover the costs of the supplies you need at home, or provide special beds. Many cities also offer advice centers for carers where you can find help with pressure sore prevention.

If you notice any skin changes that you think could be a problem, you should tell a nurse or doctor immediately. They can take a closer look. The main thing is to quickly reduce the pressure on that part of the body.

Author: German Institute for Quality and Efficiency in Health Care (IQWiG)

Next planned update: May, 2014. You can find out more about how our health information is updated here.

© IQWiG (Institute for Quality and Efficiency in Health Care)