Pressure ulcers are areas of damage to the skin and underlying tissue, usually occurring over bony prominences.
They are caused by:
- pressure: occurs when skin and tissue are directly compressed between bone and a support surface such as a bed or wheelchair. Blood is unable to circulate causing a decrease of oxygen and nutrients to the underlying cells;
- shear: occurs when skin and tissue are pulled in different directions, for example when a person slips down a bed or is repositioned using a dragging motion;
- friction: occurs when the skin rubs against a surface, for example the heels rubbing against a sheet.
The greatest areas at risk are those where there are weight bearing bones near the surface of the skin, for example under the bones in the buttocks - the ischial tuberosities. The shoulders, hips and heels are also at increased risk.
Both people at risk and their carers need to be aware of the importance of pressure ulcer prevention. Pressure ulcers can be painful, difficult to treat and even life threatening in extreme cases.
A prevention programme may include: regular skin assessment; use of manual handling aids and techniques; regular repositioning; continence management and the use of pressure distributing equipment.
For up-to-date information on specific products and suppliers in Ireland, visit the ‘Products Directory' and 'Suppliers’ sections of the Assist Ireland online database (www.assistireland.ie). The information in this resource can also be accessed using the telephone support service on 0761 07 9200 during office hours, or by emailing firstname.lastname@example.org.
The information contained in this document is strictly for information purposes only. There are hazards with all equipment and the suitability of any solution is totally dependent on the individual. It is strongly recommended to seek professional advice and assistance before you consider buying any type of equipment mentioned in this Information Sheet.
SUPPLY AND PROVISION
Before making any decisions about buying equipment, or making alterations to your home, it is strongly recommended to contact an occupational therapist (OT). An OT is qualified to assess your daily living needs. The OT will advise on possible solutions and will arrange for the provision of suitable equipment to those who are eligible eg medical card holders. The OT can also advise on home modifications, where appropriate, and on grants that may be available to help with the cost.
You can contact the OT for your area through the Community Care section of your Health Services Executive area. Contact details for your local services are in your local area phone book.
A public health nurse can also assess you for pressure relieving equipment. They can be contacted through the local health services.
Medical Card Holders
Equipment for people with disabilities, sometimes referred to as aids and appliances, is usually supplied free of charge to medical card holders. The card holder must first be assessed by a suitably qualified therapist who can recommend and prescribe the most appropriate equipment.
Long Term Illness Card Holders
People who have one of the conditions listed as qualifying under the Department of Health’s Long Term Illness Scheme may be eligible to receive items of equipment, essential for the primary condition, free of charge. Assessment by the relevant professional is required.
People in hospital may have aids and appliances provided free of charge when they are prescribed as part of in-hospital treatment in a public hospital.
Health Insurance Schemes
The main companies offering private health insurance in Ireland are:
- Voluntary Health Insurance (VHI)
- Laya Healthcare (formerly Quinn Healthcare)
Some policies provide members with cover for a limited number of aids and appliances under their out-patient schemes. A list of approved appliances is available on request. A claim for the reimbursement (part or full) will be subject to a member’s out-patient excess. Medical certification is usually necessary. Contact your health insurance company’s Customer Services to check if a particular appliance is covered by your policy.
Some employers have their own special health insurance schemes which provide cover for their employees. The employee’s family is also often covered. Check with the employer to see what, if any, equipment is covered under the scheme.
Private Purchase of Equipment
Private purchase may be necessary if the user is not eligible to obtain the necessary equipment from the local area health services. Some people may also choose to buy privately because they want the wider choice of equipment available on the private market.
The purchaser has the option of:
- personally funding the cost of the equipment
- applying to charities/benevolent funds etc for funding
- buying second-hand
- checking with your health insurance company, if a member, to see if, or what, reimbursement is available.
Private Purchase – Applying for a VAT Refund
VAT paid on certain equipment which is privately purchased for use by a person with a disability can be reclaimed from Revenue. The relief applies to VAT on the purchase of goods which are aids and appliances designed to assist a disabled person to overcome a disability in the performance of their daily functions. Most aids to daily living and communication aids are included. Goods designed for leisure purposes are not. An invoice clearly stating the VAT content of the total amount paid must be included with the application. Form VAT 61a is available from Revenue or can be downloaded from their website (see Useful Addresses).
Depending on the type of equipment required, a qualified therapist will assess the individual and make a recommendation to the body responsible for the provision of the equipment or to the person or agency who has requested the assessment. Generally the following applies, but the assessment process and provision may vary in different parts of the country.
- Occupational therapists will assess for aids to daily living – these include wheelchairs, mobility aids, specialised chairs, bath, shower and toilet aids, stairlifts, hoists etc.
- Physiotherapists will assess for movement, strength and balance training equipment, walking aids and exercise devices.
- Speech and language therapists will assess for communication, speech therapy, and training aids.
- Other relevant therapists and specialists may also be involved in carrying out assessments, depending on the equipment or appliance required.
All the different therapists described above are based in hospitals, community care areas, and with various voluntary agencies. For more information, contact the Community Care section of your Health Services Executive area or the relevant hospital department as appropriate.
Private Occupational Therapists
Occupational therapists in private practice can carry out assessments in the home or workplace, and if home modifications are being considered, provide a report detailing the recommendations. It is important to ensure the therapist is experienced in relation to your particular needs. Make sure to discuss fees before engaging anyone’s services, and also check what the assessment fee includes (or does not include). The profession’s representative body, the Association of Occupational Therapists in Ireland (AOTI), keeps a list of contact details of member occupational therapists working in private practice in Ireland. This list is available by contacting the AOTI (see Useful Addresses).
Physiotherapists can assess for movement, strength and balance training equipment, walking aids and exercise devices and recommend accordingly. If you wish to consult a physiotherapist you can go directly to your local chartered physiotherapist or ask your GP to refer you. It is important to ensure the therapist you consult is experienced in relation to your particular needs. Chartered physiotherapists work in hospitals and in the community where treatment is covered under the public health service. They also work in private practice and can be contacted through the profession’s representative body, the Irish Society of Chartered Physiotherapists (see Useful Addresses), or through the Golden Pages.
If you do decide to buy assistive equipment privately, it is strongly recommended to seek the advice of an appropriate therapist on the suitability of that equipment to your condition or situation. It is also recommended that you try out the equipment, if possible, before purchase.
Several factors may increase a person's risk of developing pressure ulcers:
People with decreased mobility may have difficulty relieving pressure when sitting or lying. They may be unable to reposition themselves in a chair or a bed, and may slip down in a chair, for example, producing a shearing effect. When carers assist people to reposition or transfer from a chair or bed, inappropriate manual handling techniques may also cause shearing or friction.
NEUROLOGICAL IMPAIRMENT OR SENSORY IMPAIRMENT
People with neurological impairment or decreased sensation may not feel the uncomfortable sensation of pressure building up and therefore not reposition themselves to relieve pressure. These people may not even feel when a pressure ulcer has developed.
The inability to control the bladder and/or bowel increases dampness in the buttock and thigh area, making the skin more prone to damage. Urine and faeces also contain substances that can increase the chance of skin breakdown.
A public health nurse can offer advice on the treatment and management of incontinence and can be contacted through the local health centre. A continence advisor is a specialist public health nurse who can give advice and support on all aspects of continence care and can be contacted through the local health service executive office.
TEMPERATURE AND HUMIDITY
Increased heat and humidity increase sweating which can add to the risk of skin breakdown. Skin cell function is also impaired if the skin becomes too warm or too cold, increasing the skin's susceptibility to damage.
DECREASED NUTRITION AND CIRCULATION
People with low body fat may have decreased subcutaneous fat and muscle bulk, providing little padding over bony prominences. People with high body fat have increased padding over bony prominences, but this tissue is poorly vascularised and may be more prone to shear forces. Good nutrition is also required to repair tissue and prevent ulcer occurrence. Good hydration is required to maintain the resistance and elasticity of the tissues.
In general, people who spend most of the day lying or sitting and are unable to reposition themselves effectively are at risk of developing pressure ulcers. A number of risk assessment scales are designed to assist health professionals to identify a person at risk of developing pressure ulcers, including the Norton Scale and the Waterlow Scale. When a pressure ulcer has developed, the ulcer is usually graded in the following way:
Grade1 - reddened skin which persists for more than 30 minutes after pressure has been relieved;
Grade 2 - superficial skin damage. May present as a blister or as an abrasion;
Grade 3 - full thickness skin loss not extending to bone or muscle. This grade of pressure ulcer is not usually painful;
Grade 4 - full thickness skin loss with extensive tissue damage through to muscle and bone.
REDUCING THE RISK OF PRESSURE SORES
Good pressure care needs to be practised across all activities of daily living: in the wheelchair, in bed, in the bath and on the toilet or commode. Correct pressure care equipment is an important component of any prevention programme, but should not be seen as a complete solution. A prevention programme for people at risk of pressure ulcers may include the following:
CORRECT POSITIONING IN BED OR CHAIR
People at risk of developing pressure ulcers should be repositioned throughout the day. When lying in bed, a 30 degree tilt will minimise pressure on bony prominences. Using a knee break and removing any slings or slide sheets will also protect from shear and friction. When sitting in a chair, the chair needs to support the full length of the user's thighs and keep the hips, knees and ankles at right angles. Armrests are required for user repositioning and transfers.
CHANGING POSITION OR LIFTING THE BODY
Pressure should be relieved from any part of the body at regular internals - especially over bony prominences. Areas at risk include - when lying on the back: shoulder blades, elbows, back of the head, buttocks and heels; when lying on the side: shoulder, ear, hips, thighs and ankles; when sitting in a chair: buttocks, elbows and heels.
Removing pressure completely allows time for the blood to flow normally to that area so that skin cell oxygen levels can be restored. If a person cannot change positions independently he/she will need to be repositioned or moved by a carer. It is important to use correct manual handling techniques when repositioning. The intervals at which repositioning should occur depends on the person's level of risk. A turning chart or clock may assist carers to establish an effective turning regime.
REGULAR INSPECTION OF THE SKIN
An initial inspection of a new patient or client should occur immediately on admission to hospital or when a new care team is in place. A standardised assessment such as the Waterlow scale should be used for this initial assessment.
The skin should then be inspected frequently - depending on the person's level of risk. Areas of risk should be inspected for:
- persistent redness which does not disappear after removal of pressure;
- discoloration or a change in texture of the skin;
- warmth or swelling over a bony prominence;
- breaks, blisters or abrasions to the skin.
If a person is examining him or herself, a long-handled mirror may be used.
WEARING SUITABLE CLOTHING AND USING SUITABLE BEDDING
Sitting or lying on thick clothing seams, such as those in jeans, should be avoided as this can contribute to pressure ulcers.
Bedding should be free from wrinkles, and a bed cradle may be used to decrease the pressure of bedding through the heels. Plastic or rubber backed bedding may cause an increase in moisture. Ideally, sheets and cushion covers should be two-way stretch and vapour permeable.
TAKING CARE WHEN LIFTING AND TRANSFERRING
To reduce the effect of friction and shear on the skin, appropriate manual handling techniques and equipment need to be used. Slide sheets and hoists can be useful to reduce shear when transferring or repositioning although they should not be left underneath the user.
USING BARRIER CREAMS
Some creams and oils may be recommended as a preventative measure, or to aid in healing of an existing sore. It is important to seek medical advice prior to use. When washing and drying, the skin should be treated with care, especially in at risk areas. Talcum powder should not be used as this can dry out the skin and may cake and increase friction.
USING PRESSURE RELIEF EQUIPMENT
Pressure relief equipment may include cushions, mattresses, bed cradles and joint protectors. Some products may have a pressure relief rating to assist health professionals to choose the correct pressure relieving products for their client. These rating have been provided by the product's suppliers, and are designed to provide a guide as to the pressure relieving qualities of that product. The ratings are intended as a guide only, and consultation with your health professional and the product supplier before purchasing any equipment is strongly advised.
Pressure relief products distribute pressure in a variety of ways, including conformity moisture absorption and reduction of shear. Pressure relief equipment may possess the following qualities:
Products made of water, air, gel and memory foam move and conform to the shape and movement of the body. However, these products decrease the ability to relieve pressure by leaning to one side as the surface will move with the user.
The user who finds it difficult to maintain sitting balance may find that cushions that quickly conform to the body and move do not feel particularly safe. They can also make transferring on and off the surface more difficult. If the user needs to push down on a transfer surface to gain leverage, the contents will move as soon as the body weight is lifted and the support will disappear.
If a mattress or cushion is too soft or too thin, it will become so compressed that it will allow the skin to come into contact with the surface beneath, so that any pressure relieving qualities are removed. This is known as bottoming out. Turning cushions and mattresses may help to prevent this.
Some mattresses and cushions are designed to reduce shear forces as much as possible. Mattresses and cushions which have individual balloon or egg-box-shaped surfaces, or foam mattresses and cushions which have a cross cut surface are able to move with the body so that the pull on the outer layer of skin is decreased. Also, cushions which are ramped and slope backwards decrease the likelihood of users sliding forward in the chair thereby minimising shear.
As heat increases so does the risk of developing sores. Users who tend to get hot and sweaty may prefer to use a cushion that keeps the surface temperature of the skin cool. Water and gel help to conduct the heat away from the area. Gel may be too cold for some people. Too much cold may cause the metabolism of the cells forming the skin cells to slow down so that they absorb much needed oxygen more slowly.
Standard foam mattresses and cushions and bead-filled mattresses and cushions should be avoided by people who get too hot, as they retain heat and do not let air circulate. Conversely, this type of mattress or cushion may be suitable for people who feel the cold and need their mattress cushion to act as insulation.
The amount of moisture produced may relate to the amount of heat produced and so may be influenced by the factors mentioned above. Moisture absorption also tends to be influenced by the material from which the mattress or cushion cover is made. Covers made of cotton and towelling are absorbent. Vapour permeable materials, for example platilon allow the air and water vapour to circulate so that sweating is minimised. However, it is also water resistant so that, if large amounts of fluid are spilt on it, the cushion underneath stays dry. Natural sheepskins are able to hold a high level of water vapour without feeling wet and will therefore reduce the effect of sweating. Man-made materials, such as nylon and vinyl, are not absorbent and, because they do not allow the air to circulate, may cause excess sweating.
Pressure relief cushions and mattresses are tested to criteria set by the Medical Devices Agency (MDA) in the UK. The standards on fire retardancy should be considered especially for users who smoke and/or those who are unable to get themselves out of bed or a wheelchair in an emergency.
A user with continence problems should seek help from a continence adviser as to how these can be managed or prevented. Occasional accidents may be unavoidable - so, if the mattress or cushion is likely to be damaged if it gets wet, adequate waterproofing should be provided. A material such as platilon may be used as it is both waterproof and water permeable, ie moist air can circulate through it.
Check whether the mattress, cushion and/or the cover are washable and if they can be disinfected if necessary. A platilon cover can be wiped clean, thus avoiding the need to launder the contents.
The adjustment of some mattresses and cushions requires a certain amount of dexterity initially so that the correct amount of pressure relief is provided. The means of adjustment may make it necessary for someone other than the user to check and make the adjustments. Some mattresses and cushions have power packs that could go wrong, others may need mending after a puncture or a split. In the case of a wheelchair cushion, check whether the user can carry out these checks and/or repairs, or has a carer who could help. If there is no one available to help, it may be better to choose a cushion that does not need setting up and maintaining in this way.
The portability of the cushion will be important for those users who frequently need to lift it in and out of their wheelchair or car. Some cushion materials, like gel or water, are heavy and are not easy to lift even when there are handles on the cushion.
Mattresses and cushions vary widely in price. However, expensive ones may be cost effective in the long run and better for the wellbeing of the person if they prevent sores from forming and the user from being admitted to hospital for treatment.
TYPES OF MATERIALS USED IN MATTRESSES, OVERLAYS AND CUSHIONS
AIR ALTERNATING CUSHIONS/MATTRESSES/OVERLAYS
These are made of rows of air cells which inflate and deflate alternately or sequentially for a pre-set time period. This ensures that the pressure on any given point is changing continually, so that the pressure is completely removed from that point for a short period of time. Consequently, pressure is then increased over the other areas. Care must be taken to ensure that the user can tolerate these pressures.
The sequence of inflation and deflation is controlled by a pump which is usually mains powered. The interval of inflation and deflation can also be controlled on some models.
These devices require a power pack and a pump when they are used as wheelchair cushions. This adds to the overall weight of the wheelchair. The power pack and pump should be attached carefully to the wheelchair so they do not interfere with the stability of the chair.
As with the static air cushions, they are unlikely to provide a stable base, and users may therefore need to consider their method of transfer.
STATIC AIR CUSHIONS/MATTRESSES/OVERLAYS
The pressure relieving properties of these cushions and overlays relies on the fact that they are air filled.
Regular maintenance is required to ensure the correct degree of inflation is maintained. It is essential to check the instructions as it is sometimes easy to over or under inflate.
Air is channelled within these cushions via air-filled balloons or pathways. The balloon type increases the surface area over which the pressure is distributed. The pathways help the air to circulate and to disperse the heat and moisture.
It should be remembered that air is unlikely to form a stable base and users may therefore need to consider their method of transfer.
Single or varied density
The pressure relieving qualities of foam depend on its resilience. Foam cushions come in a variety of thicknesses, sizes and densities. Sometimes a cushion will be made up of a variety of different foam densities. The variations make allowances for differences in the weight of a user. Foam deteriorates if exposed to heat or ultra violet light and should be replaced every six to nine months. To prolong the life expectancy and pressure relieving properties of a foam mattress/cushion it should be turned regularly, on a weekly basis. A high density foam base can make the cushion last longer. Foam cushions tend to be lightweight and need no adjustments or maintenance; some can be cut and sculpted to order.
Cross cut, contoured and convoluted foam allows greater conformity and can reduce friction and shear by allowing the surface to move with the user. They also provide greater ventilation for the skin than other foams, as flat surfaced foam can act as an insulator and increase skin temperature.
Heat sensitive or conforming foam with slow memory release models the shape of the body better than standard foam. The slower conforming properties of this material may enhance stability.
Gel cushions work on the principle that the weight of the user is distributed over the liquid or solid gel. The gel is able to conform to the body shape, so that the pressure is distributed over the whole area.
Gel is able to conduct heat away from the user so that the cushion is cool to sit on. Liquid gel cushions will leak when punctured and gel cushions can be very heavy unless they are combined with another, lighter material.
Care needs to be taken in relation to transfers since gel alone is unlikely to form a stable seating base. Users may therefore need to consider their method of transfer.
Water cushions can be less stable than gel (although more stable than air) and so do not provide much postural support. They are heavy to move and, if punctured, the rapid loss of contents may cause a problem. They are not stable, especially when the user is transferring, unless the flow of water can be reduced by enclosing it in multiple compartments.
COMBINATION FILLING CUSHIONS/ MATTRESSES/OVERLAYS
Cushions/mattresses/overlays that contain a combination of pressure relieving materials are usually arranged to provide a degree of stability to the seating base. The combination of different materials may have the advantage of being lighter than one material on its own.
These cushions must be positioned carefully (more difficult when there is a cover on the cushion), ie right side up and the marked front of the cushion to the front of the chair.
Air and liquid
Air and liquid cushions have a compartment for air surrounded by small water-filled cells. When inflated, the support comes from the air compartments. The water provides a cool surface to sit on.
Gel cushions with a foam base
These cushions have a foam base with a gel pad on top. The foam allows for a greater degree of stability than gel alone. Also, given that the amount of gel in the cushion is small, they tend to be significantly lighter than gel alone.
Water and foam
Water and foam cushions are made of open foam filled with water. The foam not only helps to add stability but also helps the cushion to conform to the body shape. Cold to sit on, they can therefore reduce skin temperature. However, remember that the foam will still deteriorate so that these cushions have quite a short life span.
Cushions with aperture
These cushions may be made of water, gel, memory foam or any combination of the above. They are designed to provide relief on a commode, WC or bath hoist seat.
ADVICE FOR PEOPLE WHO NEED PRESSURE RELIEF WHILST SITTING IN AN ARMCHAIR
CHAIRS WITH INTEGRAL PRESSURE RELIEF CUSHIONS
The integral pressure relief cushioning on these chairs is either on the seat base only or on the seat base and backrest. This is an alternative to adding pressure relief cushions to an existing armchair. Adding extra cushions changes the seat height and reduces the height of the armrests or reduces the depth of the chair. The position of the user is not compromised in a chair with integral pressure relief and there is less risk that the cushion will be the incorrect size, wrongly positioned or will slip.
USING PRESSURE RELIEF CUSHIONS IN ARMCHAIRS
Most pressure relief cushions are designed to work best when placed on a firm, level wheelchair seat.
When placed on a soft chair cushion they will loose some of their pressure relieving properties, as a person changes position relative to the backrests and armrest height. Altering the surface of the armchair may also affect the ability of a user to get in and out of the chair.
TYPES OF BEDS WITH PRESSURE RELIEVING FEATURES
LATERAL TILTING BEDS AND DEVICES
Lateral tilting beds
These beds turn the user from side to side, eliminating the need for turning by carers. They provide pressure relief and assist in postural drainage, that is, drainage of fluid from the lungs. Turning can be programmed or transfer facilitated.
Lateral tilting turning units
These can be used on top of a domestic bed. A longitudinally sectioned mattress is alternately inflated and deflated, which has the effect of tilting the person from side to side.
These units can be controlled by the person or the carer using a handset or can be set to automatically turn at pre-programmed intervals.
LOW AIR LOSS BEDS AND MATTRESSES
These beds and mattresses have air sacs that support the user on a cushion of air. They work by increasing the surface area in contact with the skin, therefore reducing the pressure at a particular point. Air is gradually lost and continually replaced in response to the weight distribution and movement of the user.
They can be used with or without a cover/sheet; however plastic and rubber backed sheets should not be used as they prevent air flow.
Some of these beds are not solid enough for emergency resuscitation to be effective (CPR), so they may be supplied with emergency valves to deflate the mattress rapidly in an emergency.
These beds are mostly for hospital or care home settings rather than domestic use. They are bath shaped. The pressure relief they provide is the result of pumping a large volume of air through a mass of particles, for example silicone beads, to make the particles behave as a fluid. When the air pump is stopped the beads become solid and support the user for nursing purposes. A hoist may be needed for transfers on/off these beds.
These beds are mostly for hospital or care home settings rather than domestic use. They have a fluid interior which may have a foam perimeter helping to provide stability. The fluid is cold to lie one; they can therefore reduce skin temperature. However, the fluid makes the beds very heavy and care must be taken as to where they are sited. Since, it is difficult to transfer safely from a moving base, using a hoist is recommended. Some people find the sloshing of the water very disconcerting.
Some people need to use joint protectors for comfort, protection and pressure relief. These may come in the form of a pad which is tied around the elbow or heel, or in the form of a bootee which encloses the toes. However, ensure that the fastenings do not exert pressure. They come in a variety of pressure relieving materials. The following types are available:
- Fleece joint protectors
- Fleece bootee joint protectors
- Polyester fibre joint protectors
- Air-filled or fluid-filled joint protectors
- Foam joint protectors
- Pads for walking equipment and prostheses, for example to line the socket of a prosthetic limb to protect the skin