The following information is to provide you and your carer with information on pressure ulcers, how they develop and the steps you can take to prevent them. Occasionally there may be good reasons why your treatment is different to this advice and you should discuss this with your healthcare professional.

What is a pressure ulcer?

A pressure ulcer is damage that occurs on the skin and underlying tissues due to the lack of blood and oxygen supply. This may happen due to:

Pressure:

• The weight of the body pressing down on the skin.
• Any object or device for example catheter tubing pressing on the skin.

Shearing:

This can occur if the patient slides down in the bedor chair. The skin becomes stretched and tears.

The first sign that a pressure ulcer may be forming is usually pain and discoloured skin. This may get progressively worse and eventually lead to an open wound. The most common places for pressure ulcers to occur are over bony parts of the body like the bottom, heel, hip, elbow, ankle, shoulder, back and the back of the head.

Who is at risk?

Anyone can get a pressure ulcer but some people are more likely to develop them than others. They can develop quickly in people if they are unable to move for a very short time. They can be serious, not just damaging the skin but deep layers of tissue; in severe cases, muscle and bone and can take a long time to heal.

For example, they can develop in people who:

• have problems moving and cannot change position by themselves without help.
• cannot feel pain over part or all of their body.
• have problems with bowel or bladder control (incontinence).
• currently have a pressure ulcer.
• have had pressure ulcers in the past.
• have an injury that affects movement.
• are unwell.
• have to wear a splint or body brace.
• have problems with memory and understanding, such as dementia.

Remember SSKIN

(Surface, Skin inspection, Keep moving, Incontinence, Nutrition and hydration)

Surface

Pressure relieving equipment, such as a mattress or chair cushion, may be necessary to help reduce the amount of pressure on your body.

Pressure ulcers can also occur under medical devices used to treat your condition. For example an oxygen mask, tubing, catheter, cast or neck collar. It is important that you inform a healthcare professional if you have a poorly fitting or painful medical device or if any of the equipment you have been provided with is not working or is uncomfortable.

Areas of the body where pressure ulcers are most likely to occur are:

• Sitting in bed
• Sitting in a chair or wheelchair
• Lying down

Skin inspection

You should check your skin every day when washing and dressing to check for warning signs of damage. You can use a mirror or ask a carer to check any awkward areas.

What are the warning signs?

• red patches on fair skin.
• purple / black patches on dark ski.
• swelling and blisters.
• hard or swollen areas which may be painful.

Noticing symptoms early is important so steps can be taken to prevent a pressure ulcer developing.

Keep moving

Regular movement is key to prevention, whether you’re in bed or sat out in a chair.

Simple movements such as lifting your heels, tilting to the side and lifting your bottom off the chair or bed will reduce the pressure on these areas.

Good sitting posture helps reduce pressure on bony areas. Lift the bottom regularly if you are safe to do so to relieve pressure.

If you have pressure damage to your skin, sitting or lying on the area should be avoided as it will delay healing and make the ulcer worse.

Incontinence

Damp skin may be damaged more easily by pressure, for example, urine, faeces or sweat. Keep the skin clean and dry and regularly moisturise. Incontinence must be managed properly, a healthcare professional can help you with this.

Nutrition and hydration

Eat a good diet, plenty of fresh fruit, vegetables and protein rich foods (for example, meat, fish, eggs, cheese, and dairy products). If you have enteral feeding, ensure you have all the feed and water as prescribed. Report any unintentional weight loss to a healthcare professional as this can increase your pressure ulcer risk, you may be referred to a dietitian.

Drink adequate fluids to keep your skin soft and supple.

Practical hints and tips

Your healthcare professional should advise you and your carer on how pressure is best reduced or relieved on areas of skin that are vulnerable to pressure ulcers.

Do

• Change your position frequently, while in bed or sitting in a chair, avoid being in one position for long periods of time. take good care of your skin, keep it clean.
• Try to eat a healthy balanced diet.
• Use the equipment as advised by your healthcare professional.
• Inspect your skin for changes in colour, such as red marks or purple/black discolouration.

Don’t

• Try to manage a pressure ulcer yourself – seek help from your healthcare professional.
• Sit on rubber ring cushions (may cause more damage) massage or rub pressure areas.
• Drag yourself over damp or creased bed clothes.
• Use a sheepskin to help relieve pressure – this is merely a comfort measure.
• Allow incontinence sheets to crease up under you – avoid their use if you can.

If you already have a pressure ulcer, lying or sitting on the ulcer should be avoided as this will make the ulcer worse.

Remember

It’s important to look after your skin by:

• Moving regularly.
• Eating and drinking well.
• Telling a healthcare professional if you have any pain or discomfort.

If you would like any more information or have any concerns, please speak to a healthcare professional who can refer you to the appropriate service, Neighbourhood team, tissue viability service, physiotherapist, dietitian, occupational therapist and back care advisors.

Anyone can get a pressure ulcer, but some children are more likely to develop them than others.

For example, children who:

• Have reduced mobility; for example, if you are ill and have to stay in bed or in a chair or wheelchair for long periods of time or if your illness or medical condition makes it difficult for you to change position without help.
• Have a piece of equipment that can restrict your movement or cause pressure and/or friction, for example a wheel chair, urinary catheter tubing, gastrostomy tube, splint, body brace, plaster cast, saturation probe, facemask, intravenous catheter (for intravenous medications).
• Have a poor diet and don’t drink enough water.
• Are underweight or overweight, as this can affect your mobility and skin condition allowing it to become damaged more easily.
• Have circulatory or respiratory conditions that affect your blood flow.
• Have increased moisture due to incontinence or sweat resulting in ‘nappy rash’.
• Have had a pressure ulcer in the past.
• Are seriously ill or undergoing surgery.
• Have damaged your spinal cord and/or cannot feel pain over part or all of your body.
• Currently have a pressure ulcer.
• Have long periods with a high temperature.

Remember: SSKIN
Surface

Skin inspection

Keep moving

Incontinence

Nutrition and hydration

Surface

Pressure ulcers can also occur under medical devices used to treat your condition. For example an oxygen mask, tubing, catheter, cast, splints or neck collar. It is important that you inform your healthcare professional if you have a poorly fitting or painful medical device or if any of the equipment you have been provided with is not working or is uncomfortable.

Pressure relieving equipment such as a mattress, cushion, specialist seating, may be necessary to help reduce the amount of pressure on your body.

Skin inspection

Check your skin daily – when you are washing and dressing, you can help by looking closely at your skin for the warning signs of pressure ulcer development and reporting any areas of concern to a healthcare professional immediately.

What are the warning signs?

• red patches on fair-skinned children
• purple and bluish patches on dark-skinned children
• skin may feel hot, firm or soft and (or) appear shiny
• blistering or cracks may form
• hard or swollen areas which may be painful
• pain over bony areas.

These are the areas of the body where pressure ulcers are most likely to occur:

• Head
• Shoulder blades
• Elbows
• Sacrum
• Buttocks
• Heel
• Toes

Noticing symptoms early is important so that steps can be taken to prevent a pressure ulcer developing.

Keep moving

This is done by moving around and changing position as much as possible. Encouraging and/or assisting your child to change their position as often as possible will help to relieve pressure on the bony parts of the body. If you use a wheelchair you need to move frequently in your chair to reduce pressure on your bottom. If you already have a pressure ulcer, lying or sitting on the ulcer should be avoided as this will make the ulcer worse.

Avoid pressure and friction : Ensure you are not lying on any tubing, wires or other equipment. Keep your bed sheets free from creases which can cause rubbing. Always use a slide sheet for repositioning, it is important to avoid dragging your child when moving them. If your child wears a cast, splint or body brace, alert your child’s health care professional immediately if you have any concerns.

Check equipment regularly : Ensure wheelchairs, cushions and splints are appropriately adjusted by your occupational therapist and physiotherapist and report any problems with this equipment to them as soon as possible.

Incontinence

Damp skin may be damaged more easily by pressure, for example, wee (urine), poo (faeces) or sweat.

Keep the skin clean and dry and moisturised.

Check your skin at least daily.

Good personal hygiene is important. Ask a healthcare professional for help and advice to manage incontinence.

Nutrition and hydration

Make sure you eat and drink well, eat a well, balanced diet with plenty of fresh fruit, vegetables and protein rich foods (for example, meat, fish, eggs, cheese and dairy products) or if you have enteral feeds ensure you have all the feeds and water as prescribed by your dietitian. Drink adequate fluids, particularly water, to keep the skin soft and supple.

Practical hints and tips

If you are a child’s parent and carer you have a very important role in helping to care for your child’s skin. Your health care professional should advise on how pressure is best reduced or relieved on areas of skin that are vulnerable to pressure ulcers.

Do

• change your position frequently, while in bed or sitting in a chair, avoid being in one position for long periods of time
• take good care of your skin, keep it clean and free from too much moisture
• encourage a healthy balanced diet
• use the equipment as advised by your health care professional
• inspect your skin for red marks or dark purple areas and report these as soon as possible.

Don’t

• sit on a rubber ring cushion (may cause more damage)
• massage or rub pressure areas
• drag yourself or your child over damp or creased bed clothes
• try to manage a pressure ulcer yourself – seek help from your healthcare professional.

If your child already has a pressure ulcer, lying or sitting on the ulcer should be avoided as this will make the ulcer worse.

Remember, it’s important to look after your skin by:

• Telling a healthcare professional if you have any pain or discomfort
• Moving regularly
• Eating and drinking well

If you would like any more information or have any concerns, please speak to a healthcare professional or ask your mum, dad or carer to speak to them.

Staff are able to refer you to the wound prevention and management service, Children’s Nursing team, physiotherapists, dietitians and occupational therapists if your needs are complex or if your condition is getting worse.