For anybody looking after somebody who cannot move themselves · 13 minutes
Skin does not break because somebody was careless. It breaks because one patch of it carried the weight for twenty of the twenty-four hours, and nobody was counting the hours.
Pressure damage is the most preventable serious harm in home care, and almost nobody caring for a relative has been told the three things that prevent most of it: that a pillow under the calves takes the heels out of the equation entirely, that a minute of relief every twenty minutes matters more in a chair than in a bed, and that redness which stays red when you press it is damage that has already started — and which reverses if the load comes off. This page takes the day you actually have and works out which patch of skin it is falling on, for how many hours, and which single change would take the most load off. It cannot see the skin, and it is not a risk score.
Pressure times timethe only quantity you can change is the hours
Press it and watchredness that stays red is stage one, and stage one reverses
Float the heelsa pillow under the calves, ten seconds, costs nothing
A ring or doughnut cushion, still handed out and still bought by families, does not spread the load. It concentrates everything onto the ring of tissue underneath it. If there is one in the chair, that is tonight's job.
Where the day is falling
Answer for an ordinary day rather than the best one. The tool adds up the hours of load each site takes, works out what those hours cost given the surface, the interval and the skin, and then re-runs the whole day with one single change applied so you can see which one buys the most. Nothing is saved and nothing leaves the page.
Can they shift their own weight — roll, lean, push up?
How many hours a day out of bed, in a chair or wheelchair?
How often does somebody change their position in bed?
While sitting, do they get lifted, leaned or stood for a moment?
What are they lying on?
What are they sitting on?
What is happening with the heels?
Do they slide down the bed and get pulled back up?
How dry does the skin stay?
Eating and drinking?
Is there anything on the skin now?
Who are you in this?
How it actually happens, which is not what people picture
It is pressure multiplied by time, and time is the part you control. Enough pressure to close the small blood vessels for long enough and the tissue dies from the inside outwards. Two hours of unrelieved load is the usual starting point for a reason, and eight hours of it is a different situation entirely.
Sitting is worse than lying, not better. All the weight goes through a small area under the sitting bones, so an hour in a chair loads that patch far harder than an hour in bed loads the base of the spine. The chair is often where the damage happens while everybody is pleased that the person is up.
The heels have the least warning and the easiest fix. They are bone with almost nothing over it, they are out of sight under the covers, and a pillow lengthways under the calves removes the load completely. Almost nobody is told this.
Sliding does more damage than pressure alone. Being dragged up the bed, or sliding down when the head of the bed is raised, shears the skin against the tissue beneath it and tears the small vessels. Raise the knees before the head, and lift rather than pull.
Damp skin breaks sooner. Urine, sweat and unrinsed soap soften the surface, so the same load does more harm. This is why continence and skin damage are the same conversation rather than two.
It starts in hours, not weeks. A single long unrelieved stretch — a night nobody turned them, an afternoon in a wheelchair at an appointment, a trolley in a corridor — is enough to start it. That is also why it is preventable.
The one-minute check, and what it means
Press the red patch with a fingertip for a few seconds and watch. If it goes white and then pinks up, the blood supply is working: take the load off and it settles. If it stays red, damage has started.
On dark skin, use touch rather than colour. The colour change is hard or impossible to see. A patch that feels warmer, cooler, firmer, softer or boggy than the skin next to it counts the same, and so does one that looks purple, bluish or shiny compared with its surroundings.
Look at the same four places every day: the base of the spine, the heels, the hips and the shoulder blades. Attach it to something that already happens — the morning wash, the evening change — because a check that needs remembering does not survive a bad week.
Ask when the patch first appeared, and how long that position had been held. The answer usually names the change that needs making better than any assessment does.
A blister, a graze or a purple patch is not early. That is broken or about-to-break skin, and it needs a nurse rather than a plan.
Write down what you saw and when. Two dated lines are worth more than a paragraph of impression, and they are what gets equipment ordered.
The changes that do the most, in order of how little they cost
A pillow lengthways under the calves. Free, ten seconds, and it takes the heels out of the calculation. Not a pillow under the feet, which pushes the heels up against the mattress, and never a ring around the heel.
A minute of relief every twenty minutes in the chair. Stand if they can, lean them forward and to each side, or lift them clear for ten seconds. This is the highest-value habit in the whole subject and it costs nothing but a phone timer.
A thirty-degree tilt rather than a full turn. A pillow behind the back, alternating sides, keeps the weight off the base of the spine and off the hip bone, and it is far easier on one carer than rolling somebody flat onto their side.
Ask for a pressure-relieving mattress by name. Foam overlays and air mattresses are prescribable in most systems and there is often a loan store. The request is ordinary: district nurse, GP, or the ward.
A slide sheet, and two people where possible. It is the difference between moving somebody and dragging them, and it protects your back as well as their skin.
Food, fluid and continence treated as skin questions. Weight loss, dehydration and damp skin all show up as skin that breaks sooner, and all three are things somebody else can be asked to review.
Two hours is a starting point, not a law. The right interval is the one that keeps the skin from going red, and that is discovered by looking: if a patch is red at the two-hour turn, the interval for that person on that surface is shorter than two hours. Equally, somebody on a good air mattress who shifts a little themselves may not need waking every two hours through the night — and sleep matters too. The check tells you which of those you are in.
What is not a prevention question
Skin that is broken, blistered, black or has a hole in it. That is a wound. A nurse or a doctor today, and the words to use on the phone are “pressure sore” or “pressure ulcer”.
Fever, spreading redness, heat around the area, a bad smell, or new confusion. Treat as infection: same day, and say those words. Infection from a pressure sore can make somebody very ill very quickly, particularly if they are frail or diabetic — and if they are shivering, breathing fast, drowsy or confused with it, that is not a same-day appointment but an emergency call: 112 in Europe.
Pain that is out of proportion to what you can see, or a patch that feels boggy or hard under intact skin. Deeper damage can be extensive under a small surface mark.
Anything on the heel that is black or leathery. Not to be picked at, softened or covered with a home dressing; it needs assessing.
A carer who cannot keep this up. Turning somebody through the night alone is not sustainable and saying so is not a failure. It is the sentence that gets night care, respite or equipment discussed.
Somebody dying. At the end of life the priority shifts: comfort, and not waking somebody every two hours for a turn they will not benefit from. Skin damage in the last days is not a care failure, and that judgement belongs with the nurse or doctor involved rather than with a page.
What people believe, and what is so
Believed
Rubbing a red area gets the circulation going
A ring cushion takes the pressure off
Sitting up in a chair is safer than lying in bed
Bedsores mean somebody was neglected
An air mattress means turning is no longer needed
Talc, a hairdryer or a heat lamp toughens the skin
If the redness fades, no harm was done
Actually
It damages tissue that is already under strain
It concentrates it onto the ring underneath
Sitting loads a smaller area far harder
They happen in good hospitals, in hours, from load
It lengthens the interval; it does not remove it
All three damage the surface that is protecting them
Redness that blanched is a warning worth acting on
The drill: 16 situations
Sixteen ordinary shifts and afternoons — the wheelchair at the hospital appointment, the ring cushion somebody bought, the red heel nobody looked at, the night nobody turned him. Most have a kind-looking answer that leaves the load exactly where it is. Pick your move; every answer explains why.
The card
Print it and put it where the turns happen. The first two lines are the whole of it.
PRESSURE: THE HOURS AND THE CHECK
EVERY DAY, SAME TIME AS SOMETHING ELSE
Look at: base of spine ____ heels ____ hips ____ shoulder blades ____
Press any red patch. Goes white = warning. Stays red = damage started.
Dark skin: compare with the skin beside it, and feel for warm, firm or boggy.
THE FOUR CHEAP CHANGES
Pillow lengthways under the calves so the heels hang clear ______
In the chair: lift, lean or stand for a moment every 20 min ______
Thirty-degree tilt with a pillow behind the back, alternate sides ______
Knees up before the head of the bed goes up. Lift, do not drag. ______
NEVER
Rub or massage a red area. Ring or doughnut cushions. Talc, hairdryer, heat lamp.
District nurse to show me the turn, once, in person ______
Position changes written down with times ______
TODAY, NOT A PLAN
Skin broken, blistered or black; fever, spreading redness, bad smell, new confusion.
On the phone say: “pressure sore”.
The only quantity anybody can change is how long one patch of skin carries the weight. Two hours is a starting point; the skin tells you whether it is short enough.