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Pressure area care
Risk factors Occurrence Prevention Aromatherapy
A pressure sore is an area of localised damage to the skin and underlying tissue caused by pressure, shear or friction.
 | Most pressure sores are avoidable (Nuffield Institute for Health (1995) |
| Patients who develop pressure sores may sue Health Providers (King’s Fund Centre 1989) |
Factors which increase the risk of pressure sores
| Having to stay in bed |
| Long periods in a wheelchair |
| Long periods in an armchair |
| Difficulty in moving about |
| Elderly or infirm |
| Having a serious illness |
| Incontinent |
| Diabetic |
| Stroke |
| Poor circulation |
| Poor nutrition |
| Poor hydration |
| Less mentally aware (e.g.: sedation, disabled) |
Department of Health (1994)
How do pressure sores occur?
Pressure damage The weight of the body against a hard surface such as a hard mattress or chair causes the venules and arterioles to close. If the pressure is not relieved and circulation restored, tissue death can occur within an hour.
Tissue nearer the bone can be under greater pressure than tissue nearer the skin surface due to compression against the hard surface of the bone. This can result in a small area of damage at the surface of the skin, with a larger crater of damage underneath.
Sitting has the greater risk because the weight of the whole body is concentrated on a small area of tissue (buttocks).
Shear damage Occurs to the underlying layers of tissue when attempts are made to slide a body along a surface. Due to the friction between the body and the surface, the body does not actually move but the layers of tissue underneath the surface are distorted and damaged.
Friction damage Occurs when the shearing force is sufficient to move the body along a surface (e.g.: moving up the bed). As the skin slides an abrasive action occurs which damages the skin surface with shearing damage underneath. Resulting underlying vascular damage can lead to full-thickness pressure sores.
Moisture Excessive sweat or urine can lead to a five-fold increase in risk for development of pressure sores.
Skin breakdown Once the skin starts to break down, bacteria and infection can enter the area so making healing a slow process, particularly in an immuno-compromised client.
Risk areas Include the lower sacrum, along the spine where the vertebrae is nearest the surface, the buttock or hips that are in prolonged contact with the bed or chair, and the heels and ankles where the bone protrudes and rubs against the mattress.
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Prevention
Moisture from sweating, and acid from urine and faeces can cause a rapid breakdown of the skin. When bathing, soiled areas should not be rubbed but patted dry and a barrier cream applied. Talc can further irritate the skin by drying up the natural oils so increasing damage from sweat and urine. Always wash a person as soon as they have soiled. Cotton underclothing is better than synthetic fibre as it is cooler and more absorbent.
People who are immobile or bedridden must have their position changed every 2 hours. Use pillows or specially made pads to stop the ankles and knees touching each other. Avoid dragging up the bed. Avoid plastic mattress covers and synthetic sheets as they cause the person to get hot and sweaty. Check inner foam is not contaminated. Avoid creases or crumbs in the bed as creases will imprint the skin and aggravate any sore areas. Sheets should not be tucked in so tight as to inhibit the softness of any special mattress. Use vapour-permeable draw sheets to absorb urine during the night and keep the person dry. Every morning and evening check for areas of damaged or discoloured skin - never lie anyone onto a dark or reddened area of skin as this will damage the skin further.
65% of all pressure sores are due to prolonged seating (Waterlow 1995). If the person is spending long periods sitting in a wheelchair or armchair. Use cushions containing a special load-spreading gel.
The Waterlow Risk Assessment provides a numerical scale of pressure sore risk: the higher the number, the more at risk a person is of developing pressure sores. Information on the assessment can be found at http://www.judy-waterlow.co.uk
How can Aromatherapy help?
An Aromatherapist performing back or leg massages is in a good position to observe skin integrity and can report signs of early tissue damage or risk areas to the qualified staff.
IMPORTANT There are many staff working in homes who trained years ago when one of the recommended treatments to relieve the early signs of pressure damage was to rub the area to increase the circulation. It is now accepted that this will damage the area further, particularly in the underlying tissues. DO NOT MASSAGE DISCOLOURED OR DAMAGED AREAS.
Care must also be taken if massaging areas adjacent to damage because the underlying tissue damage may extend underneath normal looking tissues.
Clients confined to chairs and wheelchairs can be encouraged to shuffle in their seat and change their seating position frequently throughout the day.
Collect leaflets on pressure relieving aids and leave them lying around for staff to see.
Make a point of talking about pressure area care in front of staff to let them know you are knowledgeable on the subject - this in turn will make them more aware.
Essential oils
Select cicatrizant and antiseptic oils such as Boswellia carteri (Frankincense), Chamomilla matricaria (German chamomile), Lavender (angustifolia and intermedia), Pelargonium graveoliens (Geranium) (Price et al. 1999, p230).
Sore skin but still intact Buckle (1997, p200) recommends applying floral waters such as chamomile and lavender, rosemary, myrtle, elderflower or rose (p201) to help sooth the area.
Broken skin Floral water compress
Deeper damage use a carrier oil with the compress to avoid the compress sticking such as Calophyllum inophyllum (Palm kernal) for its anti-inflammatory and analgestic action; Rosa rubignosa (Rosehip), or Aloe vera gel (Buckle 1997, p200). Also see Granulation
Infection
Klebsiella Salvia
sclarea (Clary sage)
Shingella E coli: Cymbopogon citratus (Lemongrass)
Staph. aures: Cymbopogon citratus (Lemongrass),
Juniperus communis var, erecta (Juniper)
Proteus vulgaris: Cymbopogon citratus (Lemongrass)
Bacillicus subtilis: Cymbopogon citratus
(Lemongrass)
Pseudomonas: Juniperus communis var, erecta
(Juniper)
Clostridium: Origanum majorana (Marjoram)
Streptoccocus: Origanum majorana (Marjoram)
Proteus: Origanum majorana (Marjoram)
E. coli: Origanum majorana (Marjoram)
Salmonella: Origanum majorana (Marjoram)
(Buckle 1997, p201)
Granulation: Macerated oils such as Hypericum (St. John's Wort) and Calendula officinalis (Calendula) encourage granulation and can be used as carriers for a compress or as barriers on intact skin in risk areas., or as a preventative measure after a massage.
Dilutions: Patch test, then use 1-4% dilution (Buckle 1997, p200).
Sprays: use 10 drops per 100ml water (Price et al. 1999, p230). Shake
well before use.
IMPORTANT
| Preparations made for sprays, lotions and creams must be made in sterile containers with keen attention to hygiene to prevent cross infection. |
| Ointments and lotions will not keep. |
| Preservative-free products are unsuitable for repeated use once opened. |
| For water sprays, prepare immediately before use with pressurised sterilised water solution, sealed saline capsules, recent cool-boiled, or bottled water, and discard the remains after use. |
Jane Ellwood
Jan 2000