How to Prevent Pressure Sores

Pressure sores can be disastrous. They are highly associated with immobility. In my last post I discussed what causes a pressure sore and what it looks like. This post is about prevention of pressure sores among people who are at risk. There are four key aspects: 1) Take good care of the skin. 2) Avoid weight loss. 3) Avoid continuous pressure on any part of the body. 4) Use pressure reducing surfaces/cushioning while in bed or sitting.

1) Take good care of the skin

It’s important to keep skin clean but not over wash. Hot water, daily showers, and strong or scented soap can dry the skin and remove protective oils.

Moisturizing cream should be applied to fragile thin skin once or twice daily. It’s important to apply it after bathing. Moisturizers provide a healthy environment. They also decrease friction against the skin. A minor injury is less likely if the skin is lubricated. Lastly, applying cream daily results in close inspection of the skin. Remember to use sunscreen outdoors during the day.

There are many brands of moisturizes including Cetaphil, CeraVe, and Nivea. Many products include oils, butters, vitamins, and minerals. Some creams contain hyaluronic acid, a natural substance in skin. Hyaluronic acid is highly effective at keeping skin hydrated. It helps skin stretch, flex and heal. There is no brand of moisturizing cream that is clearly superior. People develop personal preferences based on consistency, ease of application, smell, and price. The crucial point is to use the cream regularly.

Some people perspire heavily and do not like to use creams. Some prefer to use powders that can feel refreshing. Powders do not provide as much protection for the skin. However, some of these powders contain helpful ingredients such as hyaluronic acid. Daily use can be beneficial especially if it results in closer inspection of the skin. One important caveat is to avoid using talc powder. Talc can be very drying to the skin.

Urinary incontinence greatly increases the risk for pressure sores. Excess moisture makes the skin’s superficial layer swell and break down. Urine contains ammonia and other chemicals which damage the skin. That’s why it’s important to use a barrier cream in the private areas when a person is incontinent. Barrier creams are different from moisture creams. They are thicker and not as easy to apply. Sometimes they are called moisture barrier, diaper, or pressure sore creams. Typical examples include Baza and Desitin. People have different personal preferences. Some creams contain zinc. Zinc protects and helps heal the skin while also calming down irritation.

Absorbent pads and briefs are useful to absorb urine away from the skin. They should be changed when wet. Be sure to gently cleanse the area and apply barrier cream with each change.

2) Avoid weight loss

Underweight frail people are at increased risk for pressure sores. People with recent weight loss are at especially high risk. A “healthy” diet is not healthy if it results in further weight loss. Instead, encourage more fat and higher protein in the diet. Protein is especially important for seniors. It is required for tissue health and repair. Fat is needed to provide extra calories and fat-soluble vitamins. Also, patients should stay well hydrated for both skin health and to avoid fatigue. Some vitamins are promoted for skin health. In a person with weight loss, these are helpful. They often contain extra Vitamin A, C, and Zinc. All are linked to skin health.

3) Avoid continuous pressure on any part of the body

Continuous pressure interrupts microcirculation and damages skin. This is especially important when bone is pressing against the surface. As a result, pressure sores at the tailbone, buttocks, and heels are major problems. Sores also occur on the hips when people lay on their sides. The key is to avoid continuously high pressure on any single area of skin. Even a brief period of relief from pressure helps. This can be as simple as leaning all the way forward or from one side to the other in a chair. Lift the heel up and reposition the foot.

It’s important to be careful when repositioning. Use strategies to make it as easy as possible. Have the person help if possible. Dragging or pushing causes friction against the skin. Slight lifting is better. Light dusting of baby powder on surfaces also decreases friction.

Bed wedges or pillows are useful to keep a person from laying on the back all the time. But wedges can also decrease a person’s ability to move. It’s important to avoid wedging a person in one position for too long. Wedges are also useful to elevate the head of the bed. Sitting up in bed is important during meals and for quality of life. However, prolonged elevation can cause skin “shearing”. Layers of  skin and back  tissue pull in different directions as a person slides down. Prolonged head elevation also puts pressure on the tailbone.

Every person’s body is different. It’s important for caregivers to recognize which areas of skin are most vulnerable. Design a routine around that. A rule of thumb is to shift weight every 15 minutes while sitting and every 2 hours in bed. But any area of discoloration or irritation is a warning sign. That site needs more frequent and longer periods of pressure relief.

4) Use Pressure Reducing Surfaces/Cushioning

Some mattresses, mattress toppers, or overlays decrease the likelihood of pressure sores. They are better than a standard mattress alone. These products distribute weight more evenly. The surface “gives way” to pressure points while also providing cushioning. These products typically contain air, memory foam, or gel foam. Each product has distinct features. There is no consensus which is best. People have personal preferences. The products differ in comfort, look, feel, ease of use, and price. But avoid making decisions on price alone. Higher quality makes a difference. Look for products with very even and durable surfaces.

Alternating pressure air mattresses inflate and deflate. They are sometimes used in hospitals. But there isn’t convincing evidence that they are better at preventing sores. They also need electricity. The sound of the motor annoys some people.

Medical grade sheepskins also help prevent pressure sores. They distribute weight, decrease moisture, and provide aeration. They are also comfortable. They need to be cleaned regularly with a wool detergent.

It’s also important for frail patients to use pressure relief surfaces/pads when sitting. This is especially important if a person sits in a wheelchair for extended periods. Wheelchairs generally have poor padding both on the back and seat. Use a pad or a high quality non lumpy pillow. For some patients it is important to put padding between the knees or around the ankles as well. Medical supply companies have specialized products.

In summary, each of the four key aspects of pressure sore prevention is important. Neglect in any one aspect increases the risk of a sore.

• Take extra diligent care of the skin. For people who are incontinent, use a barrier cream. Incontinence pads and briefs are important to draw urine away from the skin.
• Avoid unintentional weight loss. Instead, emphasize calories and protein.
• Avoid continuous pressure on any part of the body. Reposition frequently. This is especially important around bony prominences.
• Use cushioning and products that are designed to decrease pressure. This is important both in bed and when a person is sitting.

Warmest Aloha,

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PS: I say it over and over again: There’s no one more important than the caregiver in the daily life of a frail person.