Pressure Care in a Wheelchair: Cushions, Shifts and Skin Checks

How a pressure sore forms

Skin and the tissue under it need blood flow. When a bony part of the body presses against a hard surface for a long time, the pressure squeezes the small blood vessels shut, so the tissue is starved of oxygen. After a few hours, or less in fragile skin, the tissue begins to die. Friction and shearing, when skin is dragged across a surface as the body slides, and moisture from sweat or urine make this worse.

The risk is highest in people who:

• cannot move themselves or change position often;
• have reduced feeling, such as after stroke, spinal injury or neuropathy, so they do not feel the discomfort;
• have thin, dry or fragile skin;
• are underweight, malnourished or dehydrated;
• have diabetes or poor circulation;
• are incontinent, so that skin stays wet; or
• sit in an ill-fitting chair or on a poor cushion.

The most common sites for wheelchair users are the sit bones (ischial tuberosities), the tailbone (sacrum and coccyx), the hips (trochanters) and the heels.

The four pillars of pressure care

1. The right cushion and chair. 2. Regular movement and weight shifts. 3. Daily skin checks and skin care. 4. Good nutrition, hydration and continence care.

1. The right cushion and chair

A pressure-relieving cushion is not optional for anyone who sits for more than an hour or two, or who is at risk of sores. A sling seat or a thin foam pad does not protect. Cushion types include:

• Foam cushions. Inexpensive; high-density foam or contoured foam spreads pressure moderately. Suitable for lower-risk users and short periods. They compress over time and need replacement.
• Gel cushions. Gel in a foam base or a bladder, which conforms to the body and helps reduce pressure and shear. Good for medium-risk users; see gel cushions for pressure relief.
• Air cushions. Cells of air that adjust to the body; very effective for high-risk users but need correct inflation and checks, and can be punctured.
• Combination cushions. Foam, gel and air layers.
• Ring and donut cushions. Not recommended for pressure relief, as they can concentrate pressure around the edge; see ring and donut cushions.

Ask a therapist to recommend a cushion based on risk, and ask how to set it up. Place the cushion with the right side up and facing forward. Use a washable cover, and replace the cushion when it flattens, leaks or loses shape.

The chair matters. A chair that is too narrow, too wide or too deep concentrates pressure; see wheelchair measurements. A flat, firm base under the cushion matters more than a hammock sling seat. Make sure the footrests are the right height, so that the thighs rest on the cushion and the weight is spread.

2. Movement and weight shifts

The best protection is to take pressure off regularly.

• Weight shifts every 15 to 30 minutes, lasting a minute or more, for those who can do them. Options include leaning forward, leaning to each side, or doing a push-up from the armrests to lift the buttocks.
• For those who cannot shift alone, a carer should help, by tilting the person gently from side to side or forward, or by using a tilt-in-space chair.
• Change position at least every two hours, getting out of the chair if possible, to lie down or to walk a few steps.
• Do not sit all day. Plan time in bed or lying down, particularly in the afternoon.
• Avoid sliding. Lift, do not drag, during transfers, to prevent friction and shear; see how to use a transfer belt.
• Check posture. Sit upright, hips well back, not slumped or tilted to one side, since slouching puts pressure on the tailbone.

If your parent has dementia or cannot remember, set a timer or a regular routine, such as a shift at every tea or meal.

3. Skin checks and skin care

Check the skin daily, in good light, at a regular time, such as during the morning wash or at bedtime. Look at, or feel:

• buttocks, tailbone and sit bones;
• hips and the outer thighs;
• heels, ankles and the back of the knees;
• elbows and shoulder blades if lying down; and
• any place where clothing or a device presses.

Look for:

• red or darker patches that do not fade within 30 minutes of removing pressure;
• warmth, swelling or hardness;
• blisters or shiny areas;
• skin that is broken, cracked or weeping; and
• pain, itching or tenderness.

A mirror on a handle helps people who check themselves. Carers should do it gently and respectfully.

Skin care:

• Wash with mild soap and warm water, rinse and pat dry; do not rub.
• Moisturise dry skin, but avoid creams in skin folds.
• Do not massage red areas, which can damage tissue.
• Use a barrier cream where skin is exposed to urine or sweat; see barrier creams and skin care.
• Wear smooth, loose clothing without thick seams or pockets under the buttocks. Remove wallets and keys.
• Avoid very hot water, and hot packs on numb skin.
• Keep nails short to avoid scratches.

4. Nutrition, hydration and continence

• Protein and calories. Healing and healthy skin need enough protein, vitamins and minerals. Ask a dietician if weight or appetite is poor; see malnutrition in older adults and how much protein do older adults need.
• Fluids. Dehydration makes skin fragile; see hydration for older adults.
• Continence. Keep skin clean and dry; change pads promptly; use breathable products; see incontinence-associated skin damage.
• Blood sugar. Good diabetes control helps; see diabetes after 60.
• Stop smoking and limit alcohol.

Equipment beyond the cushion

• Pressure-relieving mattress for the bed; see air mattress for pressure sores and preventing bedsores at home.
• Heel protectors and pillows to lift the heels off the bed.
• Tilt-in-space or reclining wheelchair for those who cannot shift weight.
• Seat belt and positioning supports to hold a good posture.
• Moisture-wicking covers.

What the early stages look like

Pressure ulcers are staged by severity.

• Stage 1. Intact skin with redness that does not fade on pressing; may be warm, firm or tender. This is the warning stage and is reversible if pressure is removed at once.
• Stage 2. Partial skin loss, a blister or a shallow open sore.
• Stage 3. Full-thickness skin loss, a deeper crater, possibly with fat visible.
• Stage 4. Deep wound exposing muscle or bone.

On darker skin, redness can be hard to see; look for changes in colour, warmth, swelling or hardness compared with the surrounding skin. See pressure ulcers: stages, wound care and prevention.

What to do at the first sign

1. Take all pressure off the area at once. Stop sitting on it. Lie down or position the person off the area. 2. Do not rub or massage. 3. Keep the skin clean and dry. 4. Call a doctor or nurse promptly, even for Stage 1. Early treatment prevents progression. 5. Review the cause: the cushion, the chair, the sitting time, moisture, nutrition. 6. Do not return to the chair until a professional says it is safe.

Seek urgent help for open wounds, black or dead tissue, a foul smell, pus, fever, spreading redness or severe pain, which can mean infection.

Making a routine

A simple daily routine helps.

• Morning: skin check, wash and moisturise, fit the cushion, sit well back.
• Every 15 to 30 minutes: a weight shift.
• Midday: lie down for a rest, and check the skin.
• Afternoon: a walk or a stretch if able.
• Evening: skin check, clean and dry, reposition in bed.
• All day: drink and eat well, and change pads promptly.

Write the routine on a chart and share it with all carers.

When to ask a professional

An occupational therapist, physiotherapist or wound care nurse can assess risk, recommend a cushion and a chair, teach weight shifts and review skin. Ask for a review at least once a year for long-term users, and whenever weight, health or sitting time changes. See a doctor for any broken skin. Our care advisors can arrange a home nursing visit and equipment.