Pressure ulcers in palliative care
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What are pressure ulcers?
Pressure ulcers are damaged areas of skin and/or tissue under the skin. They are most common over bony parts of the body, where the person’s body rests against a chair or bed.
There are different categories of pressure ulcer, ranging from intact skin that may be discoloured or painful, to open ulcers or wounds that affect the tissue under the skin. They may develop gradually over time or more quickly, over a few hours or less.
It’s important to find and treat pressure ulcers quickly to prevent pain and damage to the muscle or bone under the affected area of skin. Untreated pressure ulcers can lead to unnecessary pain, infection and someone may need to stay in hospital.
Pressure ulcers are sometimes called pressure sores, bed sores, pressure injuries or deep tissue injuries.
What are the signs of pressure ulcers?
Someone may have one or more of these signs of a pressure ulcer:
- Discoloured patches of skin:
- People with lighter skin tones may get red patches.
- People with darker skin tones may get purple or blue patches, or patches that are a different colour than the surrounding area – usually darker.
- Discoloured patches of skin that do not fade when you press them – either use a clear glass to see the colour of the skin or press gently with a finger for three seconds then release.
- An area of skin that is a different temperature or feels harder or softer than the surrounding skin.
- Swelling, pain or itchiness in the affected area.
If the skin damage gets worse, it may develop into:
- an open wound or blister
- a wound that affects the deeper layers of tissue under the skin
- a wound that reaches the muscle or bone.
What causes pressure ulcers?
Pressure ulcers are caused by ongoing pressure to the skin, for example if someone spends a lot of time sitting or lying in the same position. They can develop after only a few hours, whether the person is in hospital, a hospice, a care home or living in their own home.
They may also happen if the layers of skin are forced in opposite directions, for example when someone slides down in bed or slides across to a chair.
Another possible cause is medical or other equipment rubbing against the skin (friction). For example, catheters, oxygen tubing, glasses or shoes. Someone’s skin may also be damaged if they’re moved without using the correct moving and handling techniques.
Someone may have a higher risk of pressure ulcers if they:
- spend a lot of time in bed or a chair
- aren’t able to move easily, for example because they feel sore, are short of breath or have low mood
- have bladder or bowel incontinence
- aren’t getting enough nutrition from what they’re eating
- have dementia
- have a history of pressure ulcers
- have diabetes, smoke heavily or have circulation problems
- have lost sensation in their skin due to their illness or medication.
You should regularly assess someone’s risk of getting pressure ulcers. If you haven’t had training on this, ask your manager if there’s training you can attend.
Pressure ulcers towards end of life
When someone is nearing the end of their life, they are at greater risk of pressure ulcers. This is because they may not be moving around or eating and drinking as much. Incontinence can damage the skin, making it harder to keep skin dry and the skin is less able to repair itself.
You can help prevent pressure ulcers towards the end of life. Ask the person what would help them to keep comfortable.
If someone has a pressure ulcer towards the end of life, the focus of treatment will be more about making sure the person is comfortable, rather than healing the pressure ulcer. If the person agrees, you can show their family, friends or carers how to care for them in a way that protects their skin.
How can pressure ulcers be prevented?
Local guidelines or policies will give details of procedures you should follow to prevent pressure ulcers.
The SSKIN approach is one tool for preventing and treating pressure ulcers:
S - Surface
- Use a foam or air mattress on the person’s bed – use one that is made for preventing pressure ulcers.
- Use a cushion that evenly distributes pressure on the person’s chair if they spend a lot of time sitting down.
- Make sure they avoid sitting on any area of skin that is red or discoloured.
- Avoid hot water bottles or heated pads against skin that is red or discoloured – this can increase the risk of pressure ulcers.
- Remove bedpans as soon as possible after use.
- Make sure the person isn’t sitting or lying on any medical equipment, such as drainage tubes.
S - Skin inspection
Noticing any skin changes at an early stage can help prevent skin damage getting worse. You should check and record the condition of the person’s skin regularly, for example when you help them change position. Look out for any symptoms of a pressure ulcer and record any changes in:
- skin colour
- skin temperature
- swelling
- hardness or softness compared with surrounding skin.
K- Keep moving
- Help the person change their position at least every two hours if they’re using a regular mattress or cushion, or every four hours on a mattress or cushion that evenly distributes pressure.
- If someone finds moving painful, the healthcare team may recommend moving less often or using pain relief first.
- Use equipment, such as slide sheets or mechanical lifts, to help people move in and out of bed without damaging skin.
I - Incontinence/moisture
- Help the person keep their skin clean and dry, for example by using continence products.
- Use a barrier cream or film to protect the person’s skin from moisture, for example if they have bladder incontinence.
N - Nutrition
- Help the person to eat well and drink enough fluids.
The healthcare team should give the person information about how to prevent a pressure ulcer and how to use any equipment, such as mattresses or cushions. Check whether the person or their family have any questions or worries.
How are pressure ulcers managed?
Management of pressure ulcers may include:
- covering the wound with a suitable dressing
- pain relief – someone may need to take medication such as opioids or they may have anaesthetic cream, such as lidocaine, applied to the wound dressings
- helping the person change position regularly – they should avoid sitting or lying on the pressure ulcer
- helping the person to eat a balanced diet and drink enough fluid or giving artificial nutrition and hydration (ANH) if it has been prescribed for them
- improving the pressure relieving equipment (mattresses or cushions) being used
- complementary therapies and emotional support – people may get comfort from music, touch, relaxation, distraction or a therapy animal.
The aim of treatment is to make the person comfortable and prevent any further skin damage. Speak to the person and the people close to them about how pressure ulcers are affecting them and what is important to them. For example, if someone finds it painful to have their dressings changed, you could offer pain relief beforehand, try using a different dressing or reduce the number of times you change the dressing.
Explain to the person that it’s important to change position regularly to reduce any further damage to the skin. They may find some positions more comfortable than others so bear this in mind when you’re helping them to move.
Check any pressure ulcers regularly, for example, each time you change a dressing and at least weekly. Tell the GP or district nurse if the pressure ulcer is getting worse or is causing pain or odour. Keeping the wound clean and treating any infection can help keep odour under control.
In some regions, you may have a stock of wound dressings and barrier creams to use as needed. In other regions, you will need to get a prescription from the GP.
When should I ask for help?
Contact the GP or specialist nurse if someone has any signs or symptoms of a pressure ulcer, or a pressure ulcer that is getting worse. You should also contact them if the patient has any signs of infection such as:
- swelling
- pus coming from the pressure ulcer
- cold skin and a fast heartbeat
- severe or increasing pain
- a high temperature
- change in skin colour:
- on lighter skin tones you may see redness
- on darker skin tones you may see an area of skin that's purple, blue, or different in colour to the surrounding skin – usually darker.
The GP or district nurse may refer the person to a tissue viability nurse (TVN). TVNs specialise in wound care and can assess the person and make a care plan to manage their pressure ulcers.
The TVN or district nurse will record the level of skin damage (the category or grade) and report any pressure ulcers with an open wound to a central database. This database is part of a national effort to measure the impact of pressure ulcers and improve patient safety.
Useful resources
Health Improvement Scotland: Standardsfor prevention and management of pressure ulcers
NHS Improvement. Pressure ulcers: revised definition and measurement framework
Key points
- People living with a terminal illness are at risk of developing pressure ulcers.
- Untreated pressure ulcers can lead to pain, bone or muscle damage, infection and longer stays in hospital.
- You can help prevent pressure ulcers by following local guidelines and the SSKIN approach.
- Give people at risk of pressure ulcers information about prevention and treatment and ask them what their preferences are.
- Get help straight away from the GP, district nurse or tissue viability nurse if someone shows signs of wound infection.
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Disclaimer
This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals.
The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.
