A guide to pressure ulcers and pressure relief equipment

Pressure care is a vital area of medicine. Despite pressure care being high on the health and social care agenda of late, prevalence of pressure ulcers is still high and treating them costs the NHS over £1.4 million a day. Around 1,300 new ulcers are reported each month (Source NHS Digital) with up to 200,000 people developing a new pressure ulcer in 2017/18 (Guest et al 2017).

Obviously, prevention is key. There are a range of products that can help prevent pressure sores, but first, let’s explore what we mean by pressure sores.

What are pressure sores?

Also known as pressure ulcers, pressure injuries, bed sores, or decubitus ulcers. Pressure sores are localized areas of damaged skin and tissue. The extent and appearance of the damage can vary, and so clinicians use a universal four-category system to record and communicate severity.

Pressure sores can affect anyone, but people who spend prolonged periods in chairs or beds are more at risk. They have the potential to develop on all parts of the body, but are more common in areas in which bones are close to the surface of the skin, such as heels, elbows and the coccyx.

Category One

Early stages of a pressure sore are often characterized by distinct areas of skin that are:

• Discoloured
• Itchy
• Painful
• Excessively warm or cold
• Swollen
• Have an unusual texture

Category Two

If no changes are made to the person’s care, category one pressure sores can quickly develop into open wounds that can resemble ulcers or blisters.

Category Three

If left untreated these blisters can open up to reveal deeper damage.

Category Four

The highest level of severity, category four is assigned to sores that have opened so deeply that the full extent of the damage beneath is now visible and you may be able to see muscle and bone.

What causes pressure sores?

A pressure sore is caused by an area of tissue being exposed to a prolonged period of pressure. This pressure is usually caused by the natural weight of a person pressing against a surface, such as armchair seat or mattress. This pressure inhibits blood flow and after time, the reduced blood flow can cause the tissue to die. Pressure ulcers are more common in areas of skin that cover bony prominences because there isn’t as much muscle and fat to protect the blood vessels.

Friction and shear can also lead to skin damage. Friction is caused by the skin rubbing against another surface.
Shear is caused when a force is applied to the body. For example, if a person is lying in a profiled bed, gravity will eventually pull the body down towards the foot end of the bed. However the skin that is closest to the surface of the mattress may not move as quickly and therefore the person’s mass will slowly drag the skin with it. This force can inflict the same damage on the skin and tissue as prolonged exposure to pressure.

What are the health implications associated with pressure sores?

The most common complication caused by pressure ulcers is infection. Bacteria around the wound can lead to an infection in the skin and tissues, called Cellulitis. Cellulitis leads to red, swollen skin that is often painful. Infection can also occur in joints (this is known as septic arthritis) and bones (osteomyelitis). Joint and bone infections can lead to damaged cartilage and can inhibit movement of the joints and limbs.

In very serious cases, pressure wounds can lead to cancer and sepsis – but this is rare.

How can we prevent pressure sores?

The last blog we wrote on pressure sores explored ways to protect people from developing ulcers. These include:

• Regular rotation
• Eating healthily and staying hydrated
• Comfortable positioning
• Good hygiene
• Pressure care mattresses

Let’s take a look at four products/product ranges that can help you achieve this.

1. Using the VENDLET Patient Turning System to regularly rotate patients

Manually turning patients in bed is a job for at least two people and is fraught with risk, even when best practice is employed. In fact, people working in the health and social care sector have an above-average risk of experiencing a musculoskeletal disorder.

Being manually turned is also deeply undignified for patients. But to prevent pressure sores, patients must be regularly rotated. One possible solution is to employ a mechanical turning aid, like the VENDLET V5S Patient Turning System. The system allows just one carer to turn a patient. The movement is smooth and controlled, and so ideal for patients who are experiencing higher levels of pain. It’s also much more hands-off, which eradicates the risk of musculoskeletal damage to the carer as well as boosting dignity for the patient.

2. Using LEJRELET Bed Positioning Cushions to distribute pressure

LEJRELET cushions can be used to distribute surface pressure more evenly and therefore reduce the risk of pressure damage. Studies have shown that pressure injuries are much less likely to occur when patient positioning is varied. For example, the LEJRELET Wedge can be used flat to provide an effective 30 degree supine tilt, leaving the sacral area free of pressure. Whereas the LEJRELET Pad Low can be used flat, coiled, bent or folded to give effective pressure relief to the heels, legs, knees, arms and hands.

3. Choosing a pressure relief mattresses or overlay

There are three main kinds of pressure relief mattress – foam, air and hybrid.

Typically, foam mattresses work by distributing the pressure over a larger contact area. A dynamic air alternating mattress pumps air into different parts of the mattress at different times. This makes parts of the mattress firmer and therefore exposes the body to different pressure levels that alternate to provide relief. The constant changes in pressure also stimulate blood flow, which is crucial to maintaining healthy tissue. An air mattress will typically allow for greater immersion into the surface, something which can be positive but also could restrict mobility (and therefore independence) for some individuals.

Occasionally, individuals report motion sickness with the constant movement of an air mattress and in this case, a hybrid foam-air mattress could be considered. These typically provide the comfort of a foam lying surface but with the additional pressure relief of air cells underneath.

Varying levels of support for pressure care

There are lots of different types of pressure-relieving mattresses and mattress toppers (overlays). The one you should choose will depend on patient assessment. Let’s take a look at the differences between the different types, and who they may be suitable for.

Static foam mattress overlays

Generally made from flat foam or foam chips, these unsophisticated mattress toppers may be suitable for people vulnerable to developing pressure sores. They are cheaper than the high-specification foam mattresses but don’t tend to last as long, and so may be uneconomical in the long run. Also, if you’re considering using an overlay on top of a mattress, you should check that the side rails still come high enough above the mattress to prevent the user from falling out of bed.

May be suitable for people who are vulnerable to developing pressure sores.

High-specification static foam mattresses

The foam used to make these mattresses is generally very dense or is made up of visco-elastic foam. This makes them more effective at moulding to the contours of the body and helps to redistribute pressure more efficiently than standard foam mattresses that the majority of people sleep on. The surface may also help to reduce shear and friction.
As foam is an effective insulator, some foam mattresses are ‘castellated’ – meaning they have criss-crosses cut into the foam. This helps to increase ventilation and mould to the person’s shape to maximise contact area.

May be suitable for people who are vulnerable to pressure sores or already have category one to two pressure sores.

Alternating air overlays

These mattress toppers are made from one layer of air cells which inflate and deflate alternately according to a timer. This effectively helps to alternate which parts of the body are exposed to pressure, a bit like a flamingo changing which leg it’s standing on.

As with foam overlays, if you’re considering using an alternating air overlay on top of a mattress, you should check that the side rails still come high enough above the mattress to prevent the user from falling out of bed.
May be suitable for people who are vulnerable to developing pressure sores.

Alternating air mattresses

Alternating air mattresses are used in lieu of a ‘normal’ mattress and are comprised of layers of air cells. These air cells inflate and deflate in the same fashion as the air cells used in alternating air overlays.

May be suitable for people at a higher risk of developing pressure sores (for example, bariatric users) as well as those who already have category three or four pressure sores.

Hybrid mattresses

Hybrid mattresses combine the technology of high-specification foam and air-pumped mattresses. The air cells generally sit in a layer beneath the foam, and so the mattress feels more like a ‘normal’ mattress than an entirely air-pumped model. Some clients dislike the feeling of motion that can come from an entirely air-filled mattress.

May be suitable for people at a higher risk of developing pressure sores (for example, bariatric users) as well as those who already have category three or four pressure sores.

Using Fleece Protectors to protect against pressure and shearing

Lambswool fleece protectors cushion the bony areas more at risk of developing pressure sores by absorbing pressure. A whole sheet of lambswool fleece can be used to cover the mattress or chair seat, or specifically-shaped protectors can be purchased to fit the elbows and heels. These should not be used instead of a specialist mattress but may help to further reduce the risk.

We hope this guide has been useful

If you have any concerns regarding pressure ulcers, or if either yourself or someone you know is experiencing soreness or redness, then please contact a GP and request a visit from the district nurse.

And if you have any questions about pressure care equipment, please contact the Felgains team on [email protected] or 01473 741 144.