Skin Integrity: Beware the Danger of Pressure ulcers!

If your relative is immobile, or remains in a sitting or lying position for prolonged periods of time, PLEASE make sure that their skin integrity is  regularly assessed for pressure damage!

We hear too many sad stories of vulnerable and fragile patients who are left without any adequate pressure care. Failure to address this basic need can result in a rapid deterioration in their health and, more critically, an untimely demise – which is all so easily preventable with proper skin care.

Don’t assume everything is done correctly! Skin assessments can, and do, frequently get overlooked or rushed, and this can lead to incorrect care plans being implemented and/or inadequate steps then being taken to assess, monitor and prevent harm caused by pressure damage.

So, if your relative is being admitted to hospital or is going into a care facility – be alert to the risk of early pressure damage. Check that the hospital and care home are on top of the situation PROMPTLY upon admission and within [6] hours from the point of entry into acute care (NICE 2005). Monitoring should take place thereafter during their stay as an in-patient at hospital or resident in a care home, to ensure any changes to skin and pressure areas are readily identified.

You place your relative’s care in their professional hands, but we strongly recommend that you still need to check that they have assessed the risks of pressure damage correctly and also have a suitable care plan in place to inspect, monitor and prevent damage from occurring in the first place, or else deteriorating under their supervision and care.

Unfortunately, pressure damage can develop rapidly, sometimes within hours, and can turn nasty very quickly if not monitored and treated effectively. In some cases it can become a life-threatening event and can in some cases prove fatal.

Other names for pressure ulcers

Pressure ulcers are otherwise known as pressure sores or bed sores; sometimes referred to as deep tissue injury (DTI).

What is a Pressure ulcer?

A pressure ulcer is a localised injury to the skin and or underlying tissue usually over a bony prominence e.g. elbow, coccyx/sacrum area (lower back), buttocks, ankle and heel. Caused by prolonged pressure on the skin, rubbing or sheering, causing injury to the skin and underlying tissue.

When do pressure ulcers develop?

Most commonly, after an accident, surgery, stroke, paralysis, or with patients who are clinically obese, have coronary heart disease, peripheral vascular disease, diabetes, MS, dementia or Parkinson’s i.e. common scenarios where patients are most likely to be left sitting or lying in one position for long periods of time.

How do Pressure ulcers develop?

Pressure ulcers are caused when soft tissue (skin) is compressed over a bony prominence.

Predominantly they are due to immobility. So, typically, wheelchair users or those who are bedbound are therefore at high risk, usually a result of prolonged sitting or lying in one position for too long.

Who is most susceptible?

The frail, elderly, those with cognitive impairment (eg advanced dementia), thin skin and/or who are immobile.

Other contributing factors

Apart from severely limited mobility, other factors which can increase the risk of developing pressure ulcers include:

• Tissue Malnutrition: – dry, moist, undernourished, and fragile/aged skin is generally more at risk of pressure damage than nourished, hydrated skin. terminal cachexia (a wasting syndrome that leads to loss of skeletal muscle and fat), single or multiple organ failure (eg heart, kidneys, lungs), smoking, anaemia;
• Neurological deficit:- e.g. significant cognitive impairment, diabetes, MS, stroke (CVA), or paraplegia;
• Major surgery or trauma: – e.g. orthopaedic / spinal;
• Poor cognition: eg dementia/Alzheimer’s or suffering from a stroke or brain injury – where the individual may not know that the skin is being damaged and they need to reposition themselves;
• Medication: – cytotoxics (substance or process can damage cells or cause them to die), long term/high dose steroids;
• Weight loss: – often a critical factor in increasing the risks (as there is less protective skin around bony areas);
• Poor circulation: and lack of movement and adds pressure to key vulnerable areas;
• Lack of sensation: – to recognise that the area of skin is being compressed and damaged;
• Incontinence: – poor bladder and bowel care and hygiene. Accidents and sitting in soiled clothes for hours on end whilst waiting for care can increase the risk of pressure damage;
• Nutritional deficiency (diet) and fluid intake: – the body has less protective fatty layers over bony prominences; dehydration and reduced energy levels can exacerbate periods of prolonged inactivity (sitting/lying), muscle wastage and can lead to infection and a vicious spiral of more immobility – ever increasing the risks of pressure damage;
• Pre-existing vulnerability: – those with a pre-existing history of pressure ulcers;
• Communication: those with poor communication who cannot express clearly that they are in discomfort and pain (see Lacking Sensation above), or need repositioning;
• Poor wound care: an obvious cause of increased risk of infection and deterioration.

Holistically, all these factors and more, can be a cause for concern as they can individually or in combination, increase the risk of pressure ulcers.

Interestingly, you will note how many areas above are also contained within the 12 Care Domains which interact when assessing patients for NHS Continuing Healthcare Funding (Skin Integrity/Medication/Communication/Cognition/Incontinence/Nutrition etc). For more information, read these helpful articles:

Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 1

Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 2

When to carry out a risk assessment

According to NICE 2022:

“Anyone is potentially at risk of developing a pressure ulcer.

• Carry out an assessment of pressure ulcer risk for: 

 All people being admitted to secondary care or to care homes in which NHS care is provided.

 All people receiving NHS care in other settings (such as primary and community care, and emergency departments) if they have a risk factor for developing pressure ulcers, such as        significantly limited mobility or neurological impairment.

• Consider carrying out an assessment of pressure ulcer risk for all people in their own homes or in social/nursing care settings.”

Are pressure ulcers avoidable?

In short, we take the view that virtually all pressure ulcers are caused by pure neglect!

Most pressure ulcers are entirely avoidable and preventable with good care.

Failure to prevent pressure ulcers is more often a reflection of poor care, or a lack of training and understanding by care staff, and can be the subject of a negligence action – for which there is rarely any reasonable excuse.

We read in the press about care home staff shortages and patients being left too long unattended and without being repositioned frequently, or incontinent and left lying in soiled clothes (allowing damp and moisture lesions) – all contributing to fermentation of a pressure ulcer.

What’s the issue?

If elderly, frail and immobile patients, or those known to be at (high) risk, are not assessed correctly and inspected regularly by staff or ignored, pressure damage can set in quickly and deteriorate rapidly and become necrotic (going through layers of tissue to expose the bone) – making it difficult to treat successfully and can be fatal.

We have not included photos of necrotic pressure ulcers due to sensitivity, but the image associated with this blog tells you everything. You have to ask how such wounds can be allowed to develop and become so deep and infected, if not for sheer neglect.

What should hospitals and care facilities be doing?

The sooner effective preventative pressure care measures are implemented, the better. Prevention is better than cure!

Here are some pointers to check

• Was the skin examined shortly upon admission?
• Was it an accurate risk assessment of skin integrity?
• Are there body maps showing areas of actual damage or high risk? (Wrong assessments are likely to be matched with incorrect care intervention!)
• Was a care plan put in place for effective skin care?
• Are there turning charts in place for effective rotation to take pressure off key areas at risk? Does the frequency of turns match the level of risk? I.e is more frequent turning needed than stated to reduce the evident risk?
• Have the care plans and risk assessments been updated regularly?
• Is the care plan working? i.e is the patient’s skin integrity inspected regularly and the patient turned as required?
• Have there been any recommendations for pressure-relieving aids and devices such as specialist automatic repositioning mattress / pressure-relieving foam cushions to improve blood flow, heel devices etc to alleviate, offload and redistribute pressure away from vulnerable areas? (Static foam mattresses may not provide the necessary pressure-relieving benefits).

How are pressure sores assessed?

Pressure sores are usually assessed by reference to various assessment tools – the most frequently used is the ‘Waterlow’ – a risk calculation tool used by predominantly by care homes, hospitals and health professionals in the UK to recognise the potential risk of developing pressure sores. It works on a simple points score basis. (Other familiar tools include the Braden scale and the Norton risk assessment scale).

You can access a copy of the industry standard Waterlow scoring tool created by Judy Waterlow, MBE from her website judy-waterlow.co.uk. The tool has since been adapted and reformatted by hospitals and care homes alike, to create a scoring matrix to suit their own needs. See http://www.judy-waterlow.co.uk/the-waterlow-score-card.htm.

The Waterlow score includes a combination of factors that might contribute to a pressure ulcer developing including: the person’s gender, sex, age, build/weight, height, skin type, mobility, continence, recent weight loss, appetite, tissue malnutrition, medication, neurological deficit, whether the individual has undergone surgery or trauma recently. The information then provides a final score. The higher the Waterlow score, the greater the risk of pressure sores developing.

The Waterlow scores range from 0 and 49. The Waterlow score is interpreted in the following way:

• 9 or less: Patient presents little to no risk
• 10 to 14: Patient is at risk
• 15 to 19: Patient is at high risk
• 20+ : Patient is at very high risk

There are 4 grades of pressure sore, with Grade 1 being the least problematic and easiest to treat. The skin is not broken, can look discoloured, itchy or swollen, and can be treated successfully within a matter of days. As the skin breaks down and deteriorates, the grading increases through Grades 2 (partial-thickness skin loss) to Grade 3 (full-thickness skin loss), with Grade 4 being the most serious. Grade 4 is a condition where there is full-thickness skin loss and extensive destruction of tissue (it looks necrotic and black). The pain can be excruciating as the pressure ulcer is deep and can expose muscle, tendon, ligament and bone. Consequently, it can take much longer to heal (if at all), often with complications (e.g. debridement – removing dead or dying tissue; or surgery) and can be fatal in some cases.

Prevention of pressure ulcers

Remember the acronym ‘SSKIN’ used by care professionals.

Surface – ensure patients have the right support

Skin inspection – early inspection means early dectection

Keep – patients moving

Incontinence/moisture – patients need to be clean and dry

Nutrition/hydration – have the right diet and plenty of fluids

For more reading around the subject take a look at these blogs:

Has your relative been ‘made’ incontinent and developed a pressure sore?

Does the NHS Safety Thermometer’s findings impact on your relative’s entitlement to CHC Funded Care?

Summary:

PLEASE look out and check that your relative is getting proper pressure care assessments and is being monitored regularly in order to prevent them developing a pressure wound. Once evident, ensure that prompt and effective pressure-relieving measures are taken swiftly to eradicate and prevent it from deteriorating.

For more help on pressure sores we suggest you read:

NICE Guidelines – Pressure ulcers: prevention and management https://www.nice.org.uk/guidance/cg179

NHS Website – Treatment of Pressure ulcers (pressure sores)

https://www.nhs.uk/conditions/pressure-sores/

https://www.nhs.uk/conditions/pressure-sores/treatment/

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