Home Alone With a Pressure Ulcer
January 20, 2002
By Patricia Slachta, Body1 Correspondent
Home alone. Frightening words for people discharged from acute or long term care facilities with skin breakdown.
People think of skin breakdown in terms of pressure ulcers (bedsores, decubitus ulcers), but there are other causes of skin breakdown that need to be acknowledged. Moisture, friction, and shear also cause skin breakdown. Moisture issues are not just incontinence of stool or urine but may also be caused by perspiration or a draining wound. Friction and shear often occur together to cause skin breakdown. Have you noticed that when you are sitting up in bed you tend to slide down? Or as you turn side to side you slide against the sheets? These movements create friction between the skin and the sheets/bed surface. So, not only do you need to avoid pressure, you also need to consider these other three factors when trying to keep your skin intact.
Where do you start when determining how you can prevent further skin breakdown and promote healing of any breakdown already present? First you need to identify YOUR risk for further breakdown. If moisture, pressure, friction and shear are causes of skin breakdown, you can identify risk factors related to these causes.
|Causal factor||Risk factors |
|Moisture||Incontinent of urine &/or stoolPerspire enough so that your sheets are damp much of the timeWound drainage is present on your skin &/or clothing & linens|
|Immobility (you cannot change positions without assistance)Inactivity (you are confined to bed or chair)Lack of sensation (paralysis, numbness)Poor nutritionLack of mental awareness (from confusion, coma, etc.)|
Friction and shear
|Immobility (others are turning you)Inactivity (others are assisting you out of bed, into a chair, etc.|
Agitation and movement of extremities
Based on the risk factors that are unique to you, establishing a plan for preventing further breakdown is the next step.
Pay Attention to Your Skin
Regardless of the risk factors, one thing you need to do every day is look at your body. If you cannot, your caregiver should. Seeing reddened areas, noting an abrasion, finding a rash in the early stages of development is key to preventing further breakdown. Bath time is the perfect time to do this inspection. And speaking of baths, be like Goldilocks - you don't want your water too hot or too cold, plus use a minimal amount of soap on your skin as soap is drying
moisturize your skin after bathing with a lotion or cream that is absorbed
Is moisture a problem? If so, you are at even greater risk for breakdown if your skin is also subjected to pressure. Get moisture under control. Men may control exposure of the skin to moisture by using condom catheters for urinary incontinence.
Specially designed briefs for men and women absorb the urine and keep it away from the skin for short periods.
If incontinence is a problem, also seek help from a professional (urologist, continence care nurse, or the family health provider), as incontinence is often a treatable condition.
Your biggest challenge here is to keep your skin clean and dry by washing with water immediately after incontinence and patting your skin dry (no rubbing). If a pad or brief is used, protect your skin with a moisture barrier product (sprays, wipes, ointments).
Perspiring? Skin surfaces rubbing together? Use an underarm antiperspirant and pad between skin folds with a soft, cotton cloth (under breasts, in groin area, between abdominal skin folds). Use a powder with a small amount of talcum sparingly in these areas to aid in absorption of the moisture.
Monitor Your Pressure
If pressure is the culprit, your activity and mobility levels play an important role in determining the methods you use for preventing pressure breakdown. Walking, pivoting, changing positions, moving in a chair demonstrate mobility and activity. If you are unable to change your position when lying in bed or sitting in a chair, you need someone to assist with these activities on a frequent and regular schedule.
You should not lie in one position for more than one to two hours.
Don't lie directly on your hipbone, as this position does not distribute your weight evenly. Use pillows and wedges to help with positioning.
When sitting in a chair, your position should be shifted every 15 minutes when possible and changed at least every hour.
If you can shift your body in bed or in the chair, then do so hourly.
Pressure prevention MYTHS Sit on a donut ring when in the chair. (These rings actually decrease the blood flow to the area, increase swelling of the tissues in backside area and end up creating additional pressure on your skin).
Use a thin piece of foam on the bed or chair to decrease pressure. (Foam needs to be at least four inches and high density to assist in redistributing pressure).
If immobile and inactive describes your situation, consult a wound, ostomy, and continence nurse for assistance with decisions about pressure reducing product options.
If you are treating skin breakdown seek assistance from a WOC nurse and your health care provider for best treatment options and techniques.
Other techniques to help reduce friction and shear: Sit at a 30-degree angle when in bed. The higher your head is raised, the more likely you will slide (you go one way and your skin and blood vessels go the other).
Pillows and wedges also help separate bony areas (knees, ankles). Don't put pillows under your knees as this impedes circulation to and from your heart to your legs.
Have a trapeze frame placed on your bed so that you may assist with turning and getting out of bed.
Ask your caregivers to lift, not slide, your body in the bed or chair. (They can do this by using a sheet and you can help if you have a trapeze).
Don't rub your skin or do vigorous massage. This actually breaks tiny vessels under the surface of the skin.
Protect your heels from friction, shear, and pressure by keeping your heels off the bed. (There are special devices or you can use a pillow under the calf of your legs and allow your heels to hang over the edge).
Protect your elbows, especially if you use them to move around in bed. Moisturize and pad them if necessary.
About the author: Patricia Slachta, PhD, RN, CS, CWOCN, is a registered nurse specializing in long-term care and wound management. She is Chair of the Division of Health Sciences at The Technical College of the Lowcountry.
Last updated: 20-Jan-02