Preventing Bedsores at Home: Turning, Skin Checks and Surfaces

Why bedsores happen

Pressure from lying on a bony part squeezes blood vessels. Without blood, the tissue is starved. Friction and shear, caused by sliding down a raised bed or being dragged across sheets, tear fragile layers. Moisture from sweat, urine or stool softens the skin and makes it easier to damage. Heat adds to the risk.

People at higher risk include those who:

• cannot move or turn on their own;
• have reduced feeling, such as after stroke, spinal injury or neuropathy;
• are very thin, underweight or malnourished;
• are dehydrated, or have swollen legs;
• have diabetes, poor circulation or anaemia;
• are incontinent;
• have thin, dry or very fragile skin;
• are confused, sedated or very ill;
• have had a sore before.

See pressure ulcers: stages and care for the stages, and cushions for wheelchair users and pressure care in a wheelchair for sitting.

The five pillars

1. Relieve pressure by turning and positioning. 2. Check the skin every day. 3. Use the right surface, mattress and cushion. 4. Keep skin clean, dry and protected. 5. Nourish and hydrate.

Pillar 1: relieve pressure by turning

Doctors and nurses often suggest changing the position of a person who cannot move at least every two hours in bed, though the right interval depends on the person's risk, skin, mattress and condition. Some people need more frequent changes, and with a good pressure-relieving mattress the interval may be longer. A nurse can set a schedule.

A basic rotation is: back, left side, back, right side, with a 30-degree tilt on the sides rather than a full 90 degrees. A full side-lying position puts weight on the hip bone (trochanter); a 30-degree tilt spreads load across the buttock and thigh. Use pillows or wedges behind the back and between the knees to keep the person in position; see positioning a bedridden parent.

Practical tips:

• Make a turning chart, with times and positions, and tick as you go. Keep it by the bed. Several carers can share it.
• Set an alarm, including at night, if the nurse says to turn through the night. For night turning, plan so the carer is able to rest; see night-time caregiving routines.
• Use a slide sheet or draw sheet to lift and move, not drag. See turning a bedridden patient.
• Avoid lying on a red area. If a patch of skin is red and stays red after the pressure is removed, keep the person off that area until it fades, and tell a nurse.
• Heads of the bed. Raising the head of the bed by more than about 30 degrees increases shear and sliding, unless the person must sit up to eat, breathe or take medicines. Raise only as needed, then lower, and use the knee break to stop sliding; see backrests for sitting up in bed.
• Heels. Float heels by placing a pillow lengthwise under the calves so the heels do not touch the mattress, as long as the knees are slightly bent and not hyperextended.
• Sit-out time. For people who can sit, short periods in a chair with a good cushion may be allowed, but sitting is high-pressure on the buttocks, and limits are advised. See seat cushion buying guide.
• Small shifts. Even small shifts of position help, such as a pillow under one shoulder, a hand lifted, or a leg moved.

Pillar 2: check the skin every day

Look at the whole body at least once a day, and again whenever you change a diaper or clothing. Use good light, and keep the person covered and warm; ask permission and keep dignity. See dignity in intimate care.

Check these places: back of the head, ears, shoulders and shoulder blades, elbows, spine, lower back and tailbone, hips, buttocks, inner knees, ankles, heels and toes. Also under medical devices like oxygen tubing, catheters, braces and splints.

Look and feel for:

• Redness that does not fade when you press it with a finger (non-blanching). Pressing gently for a few seconds and seeing whether the skin turns white and then red again is a common check; a nurse can show you. Skin that stays red may mean early damage.
• Darker, purple or maroon patches, especially in darker skin, where redness is harder to see. Look for changes in colour, warmth, swelling, hardness or a boggy feel compared with nearby skin.
• Blisters, shiny skin or open sores.
• Pain, itching or tenderness that the person reports.
• Heat or coolness compared with surrounding skin.
• Dryness, cracks or white, soggy skin from moisture.

If you find any of these, take the pressure off the area, do not massage red areas, and contact a nurse or doctor promptly. Take a clear photo each day if you can, to show changes.

Pillar 3: surfaces

Use a surface suited to risk; see choosing an anti-bedsore mattress and air mattresses for pressure sores. Points to remember:

• A hospital bed with a good mattress helps with positioning; see hospital bed buying guide.
• Use one layer of breathable linen, smoothed to remove wrinkles and crumbs. See bed linen and fabrics for sensitive older skin.
• Do not use ring cushions or donuts; see ring cushion guide.
• Use pillows or wedges for positioning; see wedge pillow guide.
• Keep chair cushions in good order for those who sit.
• Remove objects from the bed, such as tubes, buttons and crumbs.

Pillar 4: skin care and moisture

• Wash gently with warm water and a mild soap or no-rinse cleanser. Pat dry; do not rub. Avoid hot water.
• Keep skin dry, especially in skin folds, groin, buttocks and under breasts.
• Manage incontinence. Change soiled pads at once, clean the skin, and use a barrier cream or film as the nurse suggests; see barrier cream and skin care, incontinence-associated dermatitis and how to change an adult diaper in bed. Use breathable washable underpads and avoid layers of plastic.
• Moisturise dry skin with a plain, fragrance-free moisturiser, but not between the toes or in folds where it may trap moisture.
• Do not massage red areas or bony prominences. It can damage fragile tissue.
• Avoid friction and shear. Lift and slide with a sheet, keep the head of the bed low, and keep the person from slipping down. Short nails, smooth clothing and no rough seams.
• Keep nails short to prevent scratching.
• Avoid talcum powder that clumps.
• Do not use hot water bottles or heating pads on numb skin.
• Keep the room comfortable. Heat and sweat increase risk; see keeping a bedridden parent cool in Indian summers.

Pillar 5: food and fluids

Healthy skin needs protein, energy, vitamins and water. A person who is eating poorly, has lost weight, or has swallowing problems is at higher risk and heals more slowly.

• Offer small, frequent meals and snacks with protein, such as dal, eggs, curd, milk, paneer, fish, chicken and pulses, as suits the person's diet. See indian meals for high-protein seniors and malnutrition in older adults.
• Offer fluids regularly, unless fluid is restricted by the doctor; see hydration for older adults.
• Ask a dietician or doctor about supplements if appetite is poor. Do not start high-dose vitamin or mineral supplements without advice.
• For swallowing difficulty, follow speech therapist advice; see swallowing problems and dysphagia.
• Weigh regularly if possible, or watch for signs of weight loss.

Moving and lifting

Poor handling causes many sores. Use two people for heavy turns, or use a slide sheet. Do not drag the person on a sheet. Do not pull on limbs. Protect your own back; see how to lift and transfer safely and bed transfer techniques.

Weekly routine and records

• Daily: skin check, turn chart, hygiene, fluids, meals.
• Weekly: weigh, change bedding fully, deep clean the equipment, check the mattress and cushion, review the plan with the nurse or doctor.
• Records: write down red areas, size, colour, date, and what you did. Share with the nurse at each visit; see care diary and handover notes.

When to ask a professional

Contact a nurse or doctor the same day for any skin that stays red, any blister, break, black or purple area, an area that is hot or swollen, drainage, smell, new pain or fever. A tissue viability nurse or wound care specialist can manage sores; see wound care at home for older adults. A dietician can advise on nutrition. A physiotherapist can teach turning and positioning, and an occupational therapist can advise on equipment. Seek urgent help if there are signs of spreading infection, such as fever, confusion, shivering or fast heartbeat.