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Pressure ulcers – what happened to zero tolerance?

Independent Living’s resident nutrition expert, Mary Farmer, first aspired to a career in nursing. Although she diverted into becoming a dietitian, one of the messages she held onto was the absolute importance of preventing pressure ulcers.

A career in nursing just too physically challenging

From the age of four years old, all I ever wanted to do was become a nurse. Like many little girls, that was in between being a ballet dancer and bare-back horse rider, of course!

And so, ignoring my mother’s dire warnings that I would be exhausted, I enrolled as a student nurse at one of London’s prestigious training hospitals. Dear Mother was right: night duty practically killed me, and after a bout of pneumonia, which necessitated spending Christmas in the nurses’ sick bay, I decided that maybe I would do something less arduous. Hence the switch back to college and to a career in dietetics.

However, in that short time, tramping the wards and, I have to admit, being terrified most of the time, I did learn a lot: one skill at least that has remained with me is prevention of pressure ulcers or bed-sores.

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Every patient was the personal responsibility of a specific nurse

In those days, each nurse on the ward was allocated a number of patients, which meant that you did everything for them, making sure that, as you went off duty, you asked a colleague to continue with their care and “hand over” any treatments.

For those patients who were confined to bed, or even sitting for hours on end, it was essential that they were turned regularly, or helped to stand for a few minutes. In addition, that their pressure areas, (bottom, heels, ankles, elbows and shoulders) were gently but deeply massaged with a light oil, in order to encourage circulation of nourishing, oxygenated blood to those areas and to the underlying tissues.

If left, these areas deteriorate and can, if neglected, eventually die off, leading to possible gangrene, infections and serious wounds, in some instances, exposing the bone.

Physiotherapists were also involved in prevention by regularly moving limbs and giving passive exercises. The first sign of a pressure sore developing is a slight redness of the area.

If that happened to one of our patients, the nurse responsible was fired. Simple as that! As you can imagine, prevention, rather than cure, was obvious!

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25 years on, pressure ulcers have become “one of those things”

Fast forward to my job as a community dietitian working in elderly care 25 years later, and I became aghast at the apparent lack of concern for patients in hospitals, the hospice, immobilised at home or in residential care.

I discovered that pressure sores are considered to be an occupational hazard and viewed as “one of those things”.

Figures suggest that 20% of patients in acute care settings will develop pressure sores. By this time, massaging pressure areas was “out” and instead, water beds and other pressure-relieving equipment was “in”, as research had suggested that these methods were more effective.

There were charts attached to clipboards and boxes that could be ticked on forms like the Waterlow Pressure Guide – the most widely used, albeit simplistic, tool in the UK – that told the nurse or carer just how bad the pressure area was.

Specialist posts for nurses, called Tissue Viability Nurses were invented.

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Horrific example of the consequences of neglect

I was sometimes asked by a District Nurse to accompany her on a visit to a patient so that I could see for myself.

One that has stuck forever in my mind is that of a lady who had multiple sclerosis and was totally bed-bound. She was hoisted up high and the district nurse and myself peered up into the deep, cavernous recesses of her bottom, where a pressure sore had broken down to a hole, big enough to put your fist in.

Bone was clearly visible. Not only must it have been incredibly painful but such sores can lead quickly to infection and septicaemia, placed as they are, right by the body’s effluent pathways.

If left long enough, death can result, not from the original pathology but from septicaemia – the effects of pressure sores – in other words, neglect.

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And another, closer to home

Recently, my husband’s cousin had been in hospital for six weeks, following a fall at home.

He needed help with eating and drinking which wasn’t always available. He lost a lot of weight – down to eight stone (50kg) – and developed serious pressure ulcers.

Thankfully, his wife was eventually able to move him to what she hoped was a good care home, and he was improving. Worryingly, though, he began to show signs of dementia. The question is, was this related to his malnutrition?

I am pretty sure that it wouldn’t have helped, and may well have been contributory.

He complained to his wife this week that his back was sore. She had a look – I think you know where this is going. Yes: two more pressure sores, which are already very obvious. Quickly thinking, she took some photographs on her phone.

The plot now thickens, as the staff in the home are trying to cover up for each other, claiming that he hurt himself from a tumble in the shower.

Further, it would appear that nursing records “are unavailable”.

His wife insisted that the Tissue Viability Nurse inspect these sores and confirm their definition, which she did. In addition, she called the GP who regularly visits the home. He had not heard about the pressure sores. “Where are they on his body?” he asked, which would suggest that he had not been informed and/or he had not examined her husband.

Is your blood boiling? Mine is!

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More pressure ulcers in care homes than other environments?

One website that I checked, suggested that pressure sores are more frequent in care homes, compared with patients in hospital or in their own homes. One would guess that this is due to staff shortages, with which I sympathise, but it also means that they are not doing enough prevention.

An estimated 5% of all hospitalised patients develop at least one.

“Another NHS lottery” said The Patients’ Association in their 2010 dossier on pressure sore care, or rather, lack of it.

It called for mandatory monitoring and reporting of pressure ulcers (bedsores) and estimated that around 412,000 patients will develop a new sore each year in the UK.

The costs of treatment were estimated at £1.4 – 2.1 billion per year. This figure represented 4% of the total NHS expenditure. No monetary cost can be put on the discomfort, distress and pain suffered by each unfortunate patient.

Pressure sores CAN be prevented. The risk to each patient should be properly assessed and the resulting plan implemented and updated daily.

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Why are pressure ulcers becoming more common?

Part of the problem – and probably what causes these high statistics, is the fact that so many more people are living longer and becoming incapacitated.

As one gets older, the skin gets thinner and less robust. Some medications, such as steroids, can cause “a thin skin” and a mild abrasion from even a wrinkled sheet or fold in clothing can be enough to shear the tiny skin blood vessels and cause the beginnings of a sore.

Having said that, I can call to mind an elderly lady in one of the care homes that I visited. She had more or less stopped eating and her weight plummeted to five stone – but … thanks to the amazing care that she was given, her skin was quite intact and smooth to the day that she died.

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Practical steps to prevent pressure damage occurring

To avoid constant pressure in one place, regular changing a person’s position and the intelligent placing of cushions, e.g. behind the back, between the knees and/or ankles helps.

By “regular”, one means around every two hours or so, depending on the patient.

Additional underlying health problems don’t help, such as reduced circulation due to heart problems or diabetes. Extra care is needed to ensure good blood sugar control and where there is reduced sensation.

And of course, good nutrition is essential: adequate protein; fruit and vegetables (which may have to be physically altered to suit each patient’s needs); adequate fluids and enough calories – but not more than enough – all help to keep the body well nourished.

Supplements of vitamins and minerals may also be helpful in these cases and may need to be available in liquid form. Where skin is beginning to break down, protein, iron, zinc and vitamin C are the main healing nutrients.

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Wet and soiled skin exacerbate pressure damage

If the skin is constantly wet or soiled, bedsores can quickly escalate to being very serious indeed.

I recall one patient whom I used to visit regularly with the Speech and Language Therapist. Frances had multiple sclerosis and was being fed via a gastric tube, as she had lost the ability to swallow.

On one occasion, after weighing her and checking that all was well, I asked how her sacral pressure sore was doing.

“Ah”, chipped in her husband, her main carer. “It’s not doing very well because we are allowed only three medium-size continence pads a day and so, she is wet for longer than she should be”.
“Why was this?”, we asked. “Cost, of course,” he answered curtly. “They are 3p each more expensive!”

This seemed a very silly state of affairs. I only knew the name of one person in the (as it was then) Area Health Authority and he was Director of Primary Care. I wrote on behalf of Frances and her husband, suggesting that this arrangement was not only not cost effective, considering the need for two nurses to travel to her home, change her and “anoint” her bottom, nor was it medically good, due to the fact that she had been on antibiotics for so long.

I was about to leave that particular Trust and go to another, so I was probably more arrogant than I might have been, but I felt very strongly that this was pure nonsense and bad housekeeping!

A week or so later and I had just started my new job. There was a phone call for me from Frances’s husband. “We’ve got the bigger pads!” he told me gleefully! What a triumph!

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Prevention is almost always possible

Research and experts are unanimous in stating that the overwhelming majority of pressure ulcers can and certainly should be prevented by judicious initial assessment, individual care planning for each patient and meticulous attention to preventative measures.

In its detailed guidance (see reference below), the National Institute of Clinical Evidence (NICE) advises strongly against massage; unnecessary supplementation of diet and/or hydration; electromagnetic stimulation or use of antibiotic creams.

Instead, nurses need to choose appropriate high specification mattresses and cushions, of which there are a number available.

The Tissue Viability Nurse should know which kind suits which patient’s needs.

Further, a barrier cream can be applied regularly to keep the skin dry in patients susceptible to oedema, inflammation or who are incontinent. It goes without saying, diet should be of high quality, not necessarily, quantity.

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Did you know that hospitals can be held to account for pressure ulcers?

I only learned recently that hospitals can be made accountable should patients develop a pressure sore while in their care. Most people may be unaware that they may be entitled to financial compensation for the pain and suffering caused.

“Out there” are a number of specialist legal teams who can help. Should you consider making a claim, ensure that you have the necessary evidence and proof.

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Further resources

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We have an area of Independent Living dedicated to pressure management

NICE guidance Pressure Ulcers: Prevention and Management

Includes an interactive flow chart on prevention, management and staffing, giving detailed and comprehensive advice. (Available to download as a pdf)

Judy-Waterlow.co.uk – The Waterlow Score download

Healthcare Improvement: Scotland. Adapted Waterlow Pressure Area Risk Assessment Chart

Pressure Ulcers: Risk Factors, Treatment and Prevention

You can read Mary Farmer’s nutrition articles on Independent Living, here

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  1. Francis Rutter April 19, 2017 at 9:45 am #

    In the old Norfolk and Norwich Hospital the physical medecine consultant and the head physiotherapist used to lecture the nursing staff about pressure sores and their prevention and they virtually never happened; should they actually appear then the sister and nurse concerned were “Up before the beak”.
    In the new hospital this does not seem to happen, either the lectures or the sanctions.
    In her latter 7 or 8 years my wife was bed and wheelchair bound. Despite this she never had a blemish on her skin until she dislocated her hip. It was two days before the hospital had a slot free in the theatres to reduce the dislocation and when she got home we found the sacral skin red and beginning to slough. We very soon corrected it, but it just should not have happened.

    • Frances April 19, 2017 at 11:25 am #

      Thank you for commenting, Francis – Great example of how proper care can prevent even the most immobile people from developing pressure ulcers.

  2. Rebecca April 19, 2017 at 1:04 pm #

    It seems as though the basic care is being left behind. I’m particularly concerned about the situation in care homes where it seems worse than in hospitals (and where I have several relatives). There are probably multiple reasons and not just a problem with staff shortages. The quality of staff training and awareness of the problem could be as much of a problem as the number of staff.

    • Frances April 19, 2017 at 2:30 pm #

      I think you’re right, Rebecca – if care homes think that pressure damage is something inevitable, there won’t be a proper emphasis on training staff to prevent it.

  3. Susie Hall, CareFlex April 19, 2017 at 3:22 pm #

    What an interesting article, with some real life horror stories. Appropriate seating makes a HUGE difference to people’s quality of life and, if prescribed and used correctly will help prevent pressure ulcers forming in the first place.


    CareFlex Clinical Specialist, Becca Dunstall, reports that 30% of patients in the community and around 20% of patients in nursing homes in the UK are at risk of pressure injury, resulting from improper seating.


    “If we’re thinking about a grade one pressure injury, were there may be some redness but the skin is still intact, treatment costs about £1000. For a grade four, which can see full tissue loss, even down to the bone, that’s over £24,000 to treat that one injury.


    So if we’re thinking about a 100-bed nursing home where up to 20 of those residents are at risk, we’re talking almost half a million pounds just to treat 20 pressure injuries in one home!”


    Roll that figure out nationally and, as Mary highlights, the figure is staggering.


    Specialist seating can play a very important part in alleviating the problem. Of course chairs are not magic. A person must be properly assessed to select the right chair to meet their needs. The chair must be correctly set up for the individual. That is imperative – a chair set up for someone else could cause more harm than good! And then, of course, ongoing, carers need to monitor their charges throughout the day to check they have not manoeuvred themselves back into a destructive position, or they are just not comfortable. Seating is just one part of the 24 hour posture and pressure management system. You need to get the rest right too!


    But when you think … appropriate seating can help offer people a better quality of life. It can help save health services billions. Common sense!


  4. Claire Robertson April 23, 2017 at 8:25 am #

    The very large catholic nursing home where my mother spent the last eight years of her life didn’t ‘do pressure sores’. They were always appalled when their residents returned from hospital stays with them and were adamant that the only cause was lack of care and neglect. My mother was completely immobile for the last two years, she was moved and turned regularly every few hours even during her final week of life when I was with her 18 hours a day. Incidentally they were also great believers in the merits of fresh air. When visiting in mid winter the heating would be going full blast with every other window in the corridors wide open! I will forever be grateful for the exemplary care she received there.

    • Frances April 23, 2017 at 9:54 am #

      Thank you, Claire, for sharing your mother’s experience. It is heartening to hear of institutions where zero tolerance of pressure ulcers is still the rule!

  5. Josh May 3, 2017 at 10:20 am #

    A very informed article Frances and with annual “costs of treatment were estimated at £1.4 – 2.1 billion” surely prevention is better than cure.

    • Frances May 3, 2017 at 3:05 pm #

      You would definitely think so, wouldn’t you? Especially when you add in the human cost in terms of preventable suffering…

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