Pressure Area Care

Pressure damage begins invisibly, where body weight squeezes skin and muscle against bone — sacrum, heels, hips, elbows — closing tiny blood vessels. Skin that misses its blood supply for long enough dies, from the inside out as much as the outside in. What starts as a patch of stubborn redness can, astonishingly quickly in a frail person, become a cavity down to bone that takes months to heal, if it heals at all.

The people most at risk are those who cannot easily shift their own weight: immobile, very thin or very heavy, poorly nourished, incontinent (moist skin breaks faster), diabetic, or simply too exhausted or sedated to fidget. Healthy people reposition themselves hundreds of times a day without noticing. Pressure area care is doing that noticing — and that moving — on behalf of someone who can't.

The encouraging truth: prevention is mostly unglamorous routine done reliably. Skin looked at properly every time you help someone wash or dress. Weight shifted regularly. Heels lifted free of the mattress. Wet skin cleaned and protected quickly. Food and fluids taken seriously. Redness treated as an alarm rather than a note for later. Services that do those six things relentlessly barely see serious pressure ulcers.

• Regulation 12: preventable pressure damage is unsafe care — risk assessment and mitigation are required.
• NICE CG179: pressure ulcers — prevention and management: risk assessment, repositioning, support surfaces, and care planning.
• NHS improvement frameworks (aSSKINg, React to Red) set the widely used practice bundles.
• Categories: pressure damage is graded 1–4, plus unstageable and suspected deep tissue injury — accurate grading drives reporting and response.
• Notifications and safeguarding: serious pressure damage acquired in a service commonly triggers CQC notification and local safeguarding consideration of neglect; honest records are the provider's evidence of proper care.

Assessors follow the thread: risk assessments current and recalculated after change; repositioning plans specific ("2-hourly in bed, left/right/back rotation, heels floated") with charts that match; mattresses and cushions present, plugged in, and on the right setting; body maps used at the first mark; wounds under nursing oversight with photographs and measurements where local policy allows; and nutrition linked in. Charts filled in identically to the minute all shift ("turned 10:00, 12:00, 14:00" in one pen) read as fiction — and are treated accordingly under Regulation 17.

• Check skin at every natural opportunity — washing, dressing, continence care — in good light: heels, sacrum, buttocks, spine, elbows, shoulders, ears, and under catheters, masks, glasses and splints.
• Test redness: press gently (or use a clear disc per policy) — if it stays red rather than blanching white, that is Category 1 damage. Same-day actions: pressure completely off the area, repositioning stepped up, nurse or GP informed, plan and equipment reviewed, body map completed.
• Reposition to the plan and record truthfully, including refusals — then problem-solve refusals (pain? cold? position hated?) rather than logging them nightly forever.
• Float heels with pillows lengthways under calves; heels are the most neglected site in home care.
• Manage moisture: clean and dry promptly after incontinence, barrier products per plan, no plastic-backed pads doubling as mattress protection.
• Set equipment properly: alternating mattresses have weight settings; a pump on "50kg" under a 95kg man is decoration. Check settings on every audit and after every move.
• In home care, escalate the environment: sagging armchairs, sleeping in the recliner, a divan the district nurses can't work on — report and pursue equipment.

Example 1. During a morning wash, a care assistant notices a 2p-sized red patch on a resident's sacrum that doesn't fade under gentle pressure. She doesn't just note it: pressure is kept off the area from that moment, the senior and district nurse are told before lunch, a body map is completed, repositioning goes to two-hourly, and the mattress setting is checked (it was wrong). The patch resolves in five days. A fortnight of drift would have made it a wound with a name and a safeguarding form.

Example 2. A home care client keeps refusing to go to bed, sleeping nightly in his armchair; his heels are pinking. Rather than recording refusals into a Category 3, the coordinator gets curious: he's frightened of not hearing the door since a break-in. A pendant alarm, a door chain he can use, and a profiling bed placed where he can see the hallway solve the fear — and the heels. Pressure care turned out to be burglary care.