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.

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.

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.

- 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.

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 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.

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.

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.

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.

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".

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.