Pressure ulcers: How to prevent and what to look out for

As soon as you are limited in your mobility, the risk of pressure points on the body increases. If you sit or lie in the same position for too long, pressure points will appear on your skin. Such a pressure sore is also called a pressure sore. Open wounds can develop from such pressure sores, and the tissue dies. This is also called necrosis. Therefore, it is very important to prevent such pressure sores.

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How does a pressure ulcer develop?

As a healthy and mobile person, you shift your body weight automatically. Even when you are asleep. However, as soon as you are bedridden or dependent on a wheelchair, this can be difficult. If you are no longer able to change your position under your own power, you will need help with positioning at certain intervals. We explain to you why this is the case, what you should pay attention to in order to prevent it, and what aids are available for everyday life.

Hinweis

Young people can also develop a pressure ulcer if, for example, they have to undergo a prolonged operation. If the operation lasts longer than two hours and the patient cannot be repositioned in time, the risk of a pressure ulcer is relatively high. Young people can also develop a pressure ulcer if, for example, they have to undergo a prolonged operation. If the operation lasts longer than two hours and the patient cannot be repositioned in time, the risk of a pressure ulcer is relatively high.

When you lie flat on the floor, you notice it yourself: In some places your body is directly on the floor, in other places it is not. For example, at the back you can easily put the flat of your hand between your body and the floor. But you can't do that at the shoulder blades, for example. Such prominent places, where the bones directly under the skin bear the weight when lying down, are therefore critical. The skin is compressed in these places and no longer supplied with blood. Try it out: If you press firmly on your arm with your finger, this area briefly turns white. No more blood flows in the fine veins. When you let go, the area returns to normal because blood can flow again. If you now lie or sit motionless on the prominent body parts, the skin is not supplied with blood and the tissue slowly dies. This undersupply is already visible as reddening on the skin after a little more than two hours. This is already a category 1 pressure ulcer.

Prominent body parts with increased risk of pressure sores are

- Back of the head
- Shoulder blades
- Earlobes (when lying on the side for a long time)
- Coccyx (buttocks)
- Heels

When sitting for a long time, the area around the coccyx is also the critical one. The soft buttocks themselves are not affected because no bones build up pressure under the skin there. You will not find pressure sores on the hands either. Even if they rest for a very long time, for example on the armrests of a wheelchair or on a mattress in bed: they are too light to cause serious complications.

Tip

The finger test (pressure test)

If you are caring for a bedridden relative at home, look for redness in the critical areas. Depending on the disease, those affected may not notice the onset of a pressure sore themselves. If, for example, there is partial paralysis or basic degenerative diseases weaken the body's own alarm system, the reduced sense of pain no longer offers sufficient protection against pressure sores. If you are unsure, do the so-called "finger test" on the areas in question. Press your finger on the reddened skin. If a white border forms around the reddened area, everything is OK. If the pressed area remains completely red, a pressure ulcer is present. It can be more difficult to recognise a category 1 pressure ulcer if the skin is darkly pigmented. However, the colour of the surrounding skin may differ. Pain, hardening or overheating of the affected skin area can also give a clue in this case.

Who is particularly at risk? Pressure ulcers and the risk factors

Just because an older person does not move as much as he used to, he will not get a pressure ulcer. There are risk factors that favour the development of pressure ulcers. These include
- Paralysis
- Specific damage to the skin, such as parchment skin or irritation caused by moisture, for example due to incontinence or inadequate nursing care
- Malnutrition
- Chronic underlying diseases such as diabetes, heart failure or rheumatism
- Overweight or underweight

How bad is it? Classification of pressure ulcers into the four categories

How advanced a pressure ulcer is, is classified by the division into four stages or also degrees or categories. You will come across all three of these terms if you do your own research on the subject. Ultimately, they mean the same thing.
- Pressure ulcer category 1: In the case of a category 1 pressure ulcer, reddened skin is found in the critical areas. In the so-called "finger test", the skin does not turn white, but remains unchanged red.
- Decubitus category 2: With decubitus category 2, blisters or damage in the form of abrasions have already formed.
- Decubitus category 3: The decubitus category 3 already shows an open skin area, i.e. an ulcer.
- Decubitus category 4: With decubitus category 4, the ulcers extend deep into the skin to tendons, muscles and even the bones.

How you can prevent a pressure ulcer

As soon as it is clear that you or your relative are no longer mobile enough, you should seek advice. Especially in home care, it is very important that you use special aids and pay a lot of attention to positioning. An immobile patient should be expertly repositioned at least every two hours. During their training, nursing staff learn the simple tricks that can be used to relieve pressure on critical parts of the body. There are also special hand movements that you can use to move a person into a different position.

You know?

The tissue in a pressure ulcer is not necessarily damaged from the outside inwards. It can also die first under the skin, i.e. directly at the bone, i.e. not visibly on the surface. This means that a tennis ball-sized ulcer may already be under the surface of a reddened area of skin. The red spot that you discover as a pressure ulcer category 1 by means of a finger test can therefore possibly only be the tip of the iceberg. Even if you start regular bedding immediately, the red spot may open up after a few days. Some relatives who take care of a bedridden relative themselves then stop the bedding because they think: "It's no use anyway. This is fundamentally wrong! It is precisely then that positioning must be continued! Otherwise the wound has no chance to heal and remains chronic.

Proper cleansing of critical skin areas

One of the most important measures to prevent pressure ulcers is proper hygiene of critical areas of the body. You need to know that some commercially available hygiene products damage the skin more than they care for it. Therefore, be sure to use clear water and pH-neutral soap for personal hygiene on the vulnerable areas of the skin. Always dry the skin well. Moisture softens the skin and makes it more sensitive to germs and pathogens. Creams should be moisturising. If in doubt, ask your doctor to suggest a moisturising cream to help you find the right product. If incontinence causes moisture to constantly accumulate in skin folds or in the buttocks, it is time to ask about good inserts or catheters.

hint

If a scab has formed over a pressure ulcer, you should not remove it under any circumstances. Scabs serve as protection for the body. If you remove it, you open the door to contamination of the wound. It is important to leave wound care to professionals so that you do not jeopardise the healing of the pressure ulcer.

Tips for bed storage

Basically, you should make sure that there are no wrinkles in the sheet. Even these wrinkles can increase the pressure on the critical skin areas. Catheters and tubes should be checked each time they are placed and should always be correctly padded according to the patient's body position. When positioning a bedridden patient, the nurse distinguishes between so-called "macro-positioning" and "micro-positioning".

Macro positioning: "Macro positioning" means a complete repositioning of the patient in bed. This means that the entire body is repositioned alternately from the back to the side and almost to the stomach, depending on the clinical picture. During this process, great care must be taken to ensure that certain areas of the body are additionally supported by pillows. This requires practice and expertise. That is why not every family member can do it easily. It is important that you have this positioning explained to you in detail, and if in doubt, it is better to have it done by qualified personnel from an outpatient care service. If your relative is very heavy or particularly sensitive to pain, an expert with experience can move the patient in bed in a very targeted way without putting additional strain on him or her. In addition, cables or catheter tubes can get in the way. All this belongs in the hands of skilled personnel. Not least because if an immobile patient is not positioned properly, he or she can suffocate in the worst case if his or her face sinks into the pillow and he or she cannot free himself or herself from this position.

Micropositioning: The situation is different with "micropositioning", in which the entire body is not repositioned. Only certain parts of the body are relieved by removing the pressure. This can be done, for example, with a towel roll that is pushed under the leg above the heel. Towel rolls or pillows under the mattress are also part of micropositioning. Once you have had the technique explained to you by qualified personnel, you should be able to support your relative in pressure ulcer prophylaxis yourself in the future.

hint

You cannot and should not lie down in a wheelchair. This is because a completely immobile person has almost no body tension of their own. If, for example, you put a towel somewhere under the seat cushion, similar to the position in a bed, the sitter becomes unstable. That is dangerous, he could fall out of the wheelchair. Secondly, a recumbent has even more body surface on which the shifted weight can be distributed. But if you shift the weight of a seated person, then everything is on a very small area, which increases rather than decreases the risk of pressure sores, for example on the pelvic bones. If you want to be supportive, you can encourage the person to shift weight from one half of the buttocks to the other. If you want to relieve the ischial tuberosities, the sitter can lean slightly forward with your support and only gently. Be sure to use appropriate cushions for the wheelchair, which you can get at a medical supply store. It is best to ask an expert for advice on which cushion is best suited to your case.

Aids anti-decubitus

There are numerous aids for patients with pressure sores or at a certain risk of pressure sores.

- Positioning roller
- Cube cushion
- Gel pads
- Alternating pressure mattresses

Which aid is the right one for an individual case can best be discussed with you by qualified personnel. The situation and the patient's condition determine what is necessary.
A detailed description of the individual aids for pressure ulcer prophylaxis, what they are good for and how to apply for them from the health insurance company can be found in the separate article: "Aids for pressure ulcer prophylaxis".

You know?

Some websites still list seat rings as decubitus aids. However, this is no longer up-to-date. It is true that seat rings also serve to relieve pressure on the buttocks, but only for patients who are still relatively mobile, i.e. if sitting on hard surfaces hurts because of a wound or haemorrhoids and if the user can get up again after a short time. For decubitus patients, no seat rings should be used, because the entire body weight is then only on the ring-shaped surface - which in turn promotes a pressure ulcer after a short time.

Conclusion: Be alert and take pressure ulcers seriously

The bottom line is that pressure ulcers can develop quite quickly, after only two hours. Therefore, as a carer, always pay a lot of attention to the positioning and hygiene of the body parts at risk. As soon as a pressure ulcer is present, it is essential to treat it properly and to reposition the patient regularly. Do not try to perform macro positioning yourself. This is too dangerous. Always seek professional advice and help if you are unsure.

About the author

Susanne is a trained editor, qualified caregiver for people with dementia (according to § 43b, 53c SGB XI), has completed the course to become a hospice companion and also has a husband who has been working as a geriatric nurse for 25 years and has been the owner of an outpatient care service for several years. For several years, Susanne has therefore been writing mainly on the topic of care for various media. To ensure that her texts are correct in terms of content and, above all, practical and suitable for everyday use, she obtains the information from her network of experts in the field - and always has someone who is very familiar with the respective topic proofread before publication.

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