Pressure Ulcers: Stages and Home Care

The stages

Doctors and nurses classify pressure ulcers by depth.

• Stage 1: the skin is intact but red (or darker in dark skin) and does not fade to normal colour within a few minutes after pressure is removed. The area may feel warm, firm, boggy, painful or itchy compared with nearby skin. In darker skin, redness may not show; look for a change in colour, temperature or texture.
• Stage 2: partial loss of the top layers of skin, looking like a shallow open sore, a blister or a pink or red wound bed.
• Stage 3: the skin is lost through its full thickness, with fat visible inside a crater-like wound. Muscle and bone are not exposed.
• Stage 4: the wound reaches muscle, tendon or bone, often with dead tissue and a high risk of deep infection.
• Unstageable: the base is covered with dead tissue (black, brown or yellow), so the depth cannot be judged.
• Deep tissue injury: an area of purple or maroon skin or a blood-filled blister, where deeper tissue is damaged under intact skin; it can quickly turn into an open wound.

Any open wound or suspected deep injury needs a doctor or trained nurse to assess it. Stage 1 can reverse if pressure is removed and the area is protected at once.

Who is at risk

• Immobility: bedbound or chairbound, stroke, fracture, advanced dementia, Parkinson's disease, arthritis, severe pain.
• Poor sensation: diabetes, nerve or spinal conditions.
• Moisture: urine or stool incontinence, heavy sweating, damp clothing or bedding.
• Poor nutrition or low fluid intake; being very thin or underweight.
• Poor circulation: heart, kidney or vascular disease, diabetes, smoking.
• Skin that is thin, dry or damaged; friction and shearing when sliding down the bed or being dragged.
• Illness or recent surgery; long waits on hospital trolleys or in a chair.

If your parent has several of these, treat the risk as high. See dementia stages and what each needs, stroke recovery at home guide and hip fracture recovery at home.

Checking the skin every day

Look at all pressure areas at least once a day, and each time you change position or clothing, in good light, with warm hands. Check:

• the tailbone, buttocks, hips (including the side bones), heels, ankles, backs of knees, elbows, shoulder blades, spine, back of the head and ears;
• skin under medical devices, such as oxygen tubing, tight stockings, splints or catheter tubing;
• skin folds, groin and under the breasts, where moisture and friction collect.

Look for redness that does not fade, darker or purple patches, swelling, warmth, blisters, shiny or hard areas, open skin and new pain. Press lightly on a red area for a few seconds: if it stays red or white without fading back, treat it as early damage and relieve pressure on it at once. Keep a written note of what you see and when. Take a photo if the family agrees, to compare day by day.

Relieving pressure

Pressure relief is the single most important step.

• Change position regularly. A bedridden person usually needs turning at least every two hours, or as the nurse prescribes for that person; a person in a chair needs to shift weight every 15 to 30 minutes if able, or to be helped. Use a written turning chart, with times and positions.
• Use the 30-degree tilt rather than lying flat on the side: place pillows behind the back so that the person rests on the fleshy part of the buttock, not the hip bone. Avoid lying directly on a sore area.
• Raise the head of the bed only as needed, and keep it as low as is safe for eating and breathing, because sitting upright makes the person slide and increases shear; use a knee raise or a pillow under the knees to stop sliding. See positioning a bedridden parent.
• Lift, do not drag. Use a draw sheet or slide sheet and two helpers, or ask the nurse to teach you; see how to transfer a person from bed to chair.
• Heels: keep them off the bed by placing a pillow under the calves so that the heels float, with the knees slightly bent.
• Between bony parts: use soft pillows between knees and ankles.
• Pressure-relieving surfaces: a foam or air mattress and a seat cushion spread pressure but do not replace turning. Ask the nurse which type suits your parent. See air mattress for bedsores, hospital bed buying guide, gel cushion guide and ring cushions: when they help and when they harm. Ring or donut cushions can concentrate pressure around the sore and are generally not advised.
• Limit sitting time in a chair, with a pressure-relieving cushion and regular position changes; see seat cushion buying guide.
• Encourage movement where possible: ask a physiotherapist for safe exercises and standing practice.

Protecting the skin

• Keep skin clean and dry. Wash gently with mild soap and warm water, pat dry, do not rub; clean promptly after incontinence; use soft, absorbent underpads and change them often; see incontinence care for bedridden seniors.
• Moisturise dry skin with a plain, fragrance-free product the nurse suggests; keep it away from skin folds that stay damp.
• Do not massage red or bony areas; it can damage fragile tissue.
• Avoid hot water, powders and rough towels.
• Smooth bedding and clothing: no wrinkles, crumbs or seams under the person; avoid thick folds, plastic sheets directly on skin and tight clothing.
• Protect from friction: do not let heels and elbows rub on sheets; the nurse may suggest soft protective dressings for high-risk areas.
• Keep nails short to avoid scratching.
• Manage incontinence: regular toileting routines, easy access to the toilet or commode, and a continence assessment; see bladder control in older adults.

Food and fluids

Healing and prevention need adequate energy, protein, vitamins and fluid. Offer small frequent meals with protein (eggs, dal, curd, paneer, fish or chicken if eaten, milk), plenty of fluids unless restricted and favourite foods to encourage eating. Weigh weekly. If appetite is poor or weight is falling, ask for a dietician; see malnutrition in older adults, how much protein do seniors need, indian meals for high-protein seniors and hydration for older adults. Do not start supplements without advice, particularly with kidney disease or diabetes.

Caring for an existing sore

Stage 1 (intact skin, non-fading redness). Remove all pressure from the area at once, do not rub, keep clean and dry, review the mattress, turning and nutrition, and show the area to a nurse or doctor within a day or two. If it does not improve in a day or so, or worsens, seek help.

Stage 2 or deeper, any open sore, blister, or broken skin. This needs assessment by a doctor or trained wound care nurse. Meanwhile: keep all pressure off the area; do not burst blisters; cover with a clean, dry dressing only as the nurse shows; do not apply home remedies, turmeric, sugar, honey, ghee, oils, powders, antiseptic liquids or creams unless the nurse advises; keep the area clean as instructed. Follow the dressing plan exactly and do not change it. See wound care at home for older adults.

Pain. Pressure sores hurt, especially during dressing changes. Tell the team; pain relief can be arranged, and it must come from the doctor.

Warning signs of infection or serious problems

Call the doctor the same day for: spreading redness or heat around a sore; pus or a bad smell; increasing pain; fever or chills; new swelling; a wound that is getting larger or deeper; black or dead tissue; or a sore that is not improving after a week or two of proper care. Call 112 if there is fever with confusion, fast breathing, fast pulse, shivering or collapse (possible blood infection), heavy bleeding that will not stop with firm pressure, or if the person becomes very drowsy or unresponsive.

Special situations

• Diabetes: foot and heel sores can become serious quickly; see diabetic foot ulcers prevention.
• Dementia: the person cannot report pain, so check skin daily; see dementia stages and what each needs.
• End of life: skin may break down despite excellent care; focus on comfort, gentle positioning and pain relief; see end-of-life care at home.
• After a fall or hospital stay: a person who lay on the floor for hours should have skin checked; see what to do after a fall.

When to ask a professional

A doctor or wound care nurse assesses any open sore and plans treatment. A physiotherapist teaches safe moving and positioning. An occupational therapist or nurse advises on mattresses and cushions. A dietician supports nutrition. A surgeon may be needed for deep wounds. For senior services, call Elderline 14567. In an emergency, call 112.