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Pressure Ulcers

Pressure ulcers, also called bedsores, are one of the most serious issues that clients can ever get. A pressure ulcer can be a life-
threatening disaster, destroying quality of life and causing disability, pain, suffering and even death.


But, the fact is, most are completely preventable with just a few, easy-to-do caregiving techniques.

Dedicated, compassionate caregivers can prevent most pressure ulcers. It’s not difficult – all that’s involved are a few simple caregiving skills that most anyone can quickly learn. That’s the good news.

The bad news is that all too often, caregivers fail to provide this compassionate care and far too many seniors get pressure ulcers, suffering greatly and needlessly. Often, a client with a pressure ulcer is a sign of poor, unprofessional caregiving.

Preventing pressure ulcers is not rocket science. Any knowledgeable caregiver can do it. If you just do the following simple procedures, most pressure ulcers will be prevented under your watch:

  • Make sure your immobile client sitting in a chair is repositioned at least once every hour.

  • Make sure your client is repositioned at least every two hours if on a regular mattress, four hours if on a special pressure redistribution mattress.

  • Set up a reminder system so that you’re always notified when a client needs repositioning.

  • Never let a client lie wet and soiled – always keep them dry and clean.

  • Do a daily skin check of your at-risk clients – those who are immobile, who have diabetes, or other conditions that might make them vulnerable.

  • Never drag your clients across sheets – dragging can cause tears in their delicate skin and cause a pressure ulcer.

  • Use recommended supports to keep bony areas up off the mattress.


These few recommendations would prevent most pressure ulcers if caregivers simply did them diligently every day. This is an area of care where frontline caregivers can have a huge favorable impact on their clients’ welfare and quality of life.


The big problem with pressure ulcers is that they can quickly turn into a worsening, infected, festering lesion, and become extremely difficult to heal. The reason for this is that they contain colonies of various types of bacteria, including staph, strep and e.coli.

Antibiotics are often not all that effective because of difficulties in getting the medicine through the tissue to the bacteria. In some cases, resistant bacteria get in the wounds, making the situation even worse.


Pressure ulcers are a major factor in untimely death among clients. In hospitals, those who develop pressure ulcers within six weeks are three times more likely to die. And in research in long-term care residences, development of a pressure ulcer within three months of admission was associated with a huge 92 percent mortality rate, compared to a mortality rate of only 4 percent in residents who did not develop pressure ulcers.

The answer to all this, of course, is to prevent them from occurring in the first place.

In clients who must stay in bed, most pressure ulcers form on the lower back below the waist, at the hip bone, and on the heels. For clients in chairs or wheelchairs, the exact spot where pressure ulcers form depends on the sitting position.

Pressure ulcers can also form on the knees, ankles, shoulder blades, back of the head and spine.

You need to be constantly watchful for pressure ulcer development. Clients who are unable to move may get pressure ulcers after as little as 1-2 hours in the same position. Clients who sit in chairs and who cannot move can get pressure ulcers in even less time because the force on their skin is greater – and especially if they become wet or soiled.

But here’s the problem – an hour goes by very fast in the hustle of caregiving. It’s easy to forget that your client needs to be moved. The solution – develop an alarm/reminder system that ensures you’re informed every time your client needs to be repositioned. An efficient and dependable reminder system is an absolute requirement for proper pressure ulcer prevention.


For those who have dementia, you need to be particularly watchful ... especially with those in the later stages of the disease. These clients are prone to getting pressure ulcers because they often spend large amounts of time sitting still in chairs, wheelchairs or lying in bed. And if they’re having problems or become wet or feel pain as the result of ongoing pressure on a part of their body, they often cannot tell you about it. So a pressure ulcer can develop without anyone knowing it and become serious in a hurry.

Also, they may be unable to move, or simply forget to move. You need to always keep in mind that many clients with dementia are completely dependent upon the care and alertness of frontline caregivers for the prevention of pressure ulcers.

After an accurate assessment has been developed, the National Institutes of Health has these basic recommendations for preventing pressure ulcers:

  • Watch healed ulcers closely. This is important since areas of healed Stage III or IV pressure ulcers are more likely to have recurrent breakdown.

  • Inspect the client’s skin at least once a day.

  • Bathe the client when needed for comfort or cleanliness.

  • Prevent dry skin. Use recommended creams as necessary.

  • Change the client’s position at least every 2 hours if in a bed, and every 1 hour if in a chair.

  • Use supports to keep bony areas up off the mattress.

Improper positioning and being in a position for too long of a time are the major causes of pressure ulcer development. If caregivers can learn a few simple guidelines on positioning their clients and then be very watchful and alert that the positioning guides are being followed at all times, they could substantially decrease the number of pressure ulcers that develop.

The fact is, most pressure ulcers are preventable if these precautions are followed. Here are some positioning recommendations from the National Institutes of Health and the Centers for Medicare and Medicaid services:

  • Be sure to follow medical personnel advice closely on the proper positioning of your clients. Be knowledgeable about the types and locations of positioning devices used to relieve pressure on their pressure points.

  • Make sure your clients are repositioned at least every hour for those in wheelchairs and every 2 hours for those in bed in order to shift points on their body that are under pressure.

  • For those who can do it themselves, educate them to reposition their key body points every 15 minutes.

  • Always use positioning devices such as pillows to prevent direct contact between bony prominences (such as knees or ankles).

  • A client with a pressure ulcer on a sitting surface should avoid sitting until the ulcer is properly healed unless you can determine a recommended method of relieving pressure on the ulcer.

  • Pillows or wedges should be used to keep knees or ankles from touching each other.

  • Avoid positioning clients directly on their hip bones when lying on their sides.

  • For those who are completely immobile, pillows should be put under their legs from midcalf to ankle, to keep heels off the bed. Pressure ulcers can quickly form on the heels, and it’s an area that is sometimes overlooked by caregivers. Heels should be kept up off the bed.

  • Never place pillows behind the knee.

  • Be very careful when moving clients, so that you don’t scrape their thin, sensitive skin. Even something as simple as friction against a sheet can damage their skin and cause a pressure ulcer.

  • Maintain the head of the client’s bed as low as possible, consistent with the client’s medical conditions and other restrictions.

  • Limit the amount of time that the head of the bed is elevated.

  • For those in wheelchairs, be sure you always use the recommended form, gel or air cushions to relieve sitting pressure. Do not use doughnut shaped cushions as they can reduce blood flow and increase the chances of getting a pressure ulcer.

  • Keep bedding as wrinkle-free as possible and make sure there are no crumbs or other foreign materials on the sheets.


Cross-infection can be a major problem that can increase the severity of an ulcer. This is where bacteria is transferred from one place to another on a client, or from one person to another. It can result in some very serious bacteria getting into the pressure ulcers and making them much worse than they already are. To avoid the risk of cross-infection:

  • Wash your hands with warm water and soap after wound treatment – even if wearing gloves.

  • Use a new pair of gloves for each client – but you can use the same pair of gloves for treating different pressure ulcers on the same client.

  • When treating several infected ulcers on the same person, treat the less contaminated one first.

  • Do not share packages of dressings among different clients.

  • Wear Personal Protective Equipment (PPE) if you are likely to come in contact with body substances that might soil your clothing or skin.

  • Make sure that you protect pressure ulcers from becoming contaminated with feces, especially for those who are incontinent.

Note: A properly-cleaned pressure ulcer should show evidence of some healing within two to four weeks. If it isn’t healing, then the office and/or medical personnel need to be notified immediately before it becomes life-threatening.


Do not overlook the value of nutrition for the client. Here’s what the CMS Pressure Ulcer Guidelines say about nutrition: “Adequate nutrition and hydration are essential for overall functioning. Nutrition provides vital energy and building blocks for all of the body’s structures and processes.

“Any organ or body system may require additional energy or structural materials for repair or function. Significant unintended weight loss may indicate under-nutrition or worsening health status. Continuing weight loss and failure of a pressure ulcer to heal, despite reasonable efforts to improve caloric and nutrient intake, may indicate the resident is in multi-system failure, or an end-stage or end-of-life condition, warranting an additional assessment of the person’s overall condition.”

“Water is essential to maintain adequate body functions,” says the CMS in its guidelines. “It is critical that each person at risk for hydration deficit or imbalance be identified and that hydration needs are addressed.”

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