Addressing increased skin fragility in plus size patients

Due to fluid retention and poor circulation, plus size patients can have increased skin fragility, making them vulnerable to infection, pressure ulcers and skin tears.1 To mitigate this risk, the use of appropriate therapeutic support surfaces and microclimate management solutions are recommended in guidelines from expert bodies such as the European Pressure Ulcer Advisory Panel (EPUAP).2


These International Guidelines recommend that plus size persons are provided with “pressure redistribution support surfaces and equipment appropriate to the size and weight of the individual” and consider “enhanced pressure redistribution, shear reduction and microclimate control”.2

Combating the risks associated with immobility is a vital part of plus size care. Safe working practices are essential for repositioning, sitting up and turning the patient, as the routine-related loads are greater. For quality care procedures, caregivers need to feel secure that the techniques and equipment they are using are correct for the task/activity being undertaken. Upright positioning brings a range of health benefits,3 with tissue viability often an issue, appropriate handling must be undertaken to avoid pressure damage and skin injury.4

The ability to reposition the individual, considering the patient’s clinical condition, size, appropriate equipment, and adequate staffing levels can also affect the ability to assess, prevent, and treat tissue damage. In patients who have compromised breathing, there are also conflicting priorities of positioning the patient for optimal ventilation and early mobilisation versus preventing tissue damage.5

Obesity is also responsible for a variety of changes in skin physiology, including excessive sweating, so regular skin assessment and patient repositioning can help to reduce the risk of pressure ulcers forming and the associated cost and care implications.4 Moisture management and skin fold repositioning due to the thick layers of subcutaneous fat can potentially lead to skin breakdown due to the combined forces of moisture, gravity, torsion, and a larger mass in motion.6

Maintaining sensitivity to the special needs of a plus size person and preserving patient dignity is vitally important. Patients of size often feel insecure due to their size alone as well as the special equipment required for care.4

Choosing the right bed and therapeutic surface can play an active role in the care of a plus size person, providing support for safe, ergonomic bedside routines, as well as a customised surface and microclimate management for the prevention and treatment of pressure ulcers.1

Learn more about microclimate management for plus size patients


National Pressure Ulcer Advisory Panel, European Pressure Advisory Panel and Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline Emily Haesler (Ed ) Cambridge Media: Osborne Park, Western Australia; 2014
2. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Accessed January 2019
3. Dean, E. (1999) The effect of positioning and mobilisation on oxygen transport. Cited in: Pryor JA & Webber BA (eds) Physiotherapy for respiratory and cardiac problems(2nd edition), Churchill Livingstone, London pp. 121-136
4. Muir, M A and Rush, J A (2013) Moving and Handling of Plus Size People an illustrated guide, Towcester: National Back Exchange, 9
5. Muir, M, Archer-Heese, G. (2009) Essentials of Bariatric Patient Handling Program, OJIN: The Online journal of Issues in Nursing Vol. 14, No. 1.
6. Rush, A.J. &  Muir, M. A. (2012) ‘Maintaining Skin Integrity in Bariatric Patients’, Clinical Focus British Journal of Community Nursing, 17(4), 29th March 2012. pp. 154 – 159
7. Muir, M A and Rush, J A (2013) Moving and Handling of Plus Size People an illustrated guide, Towcester: National Back Exchange, 9