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Managing Pressure Ulcers

The prevention and management of pressure ulcers (PU) continues to challenge clinicians on a daily basis. Despite large-scale improvement projects such as Stop The Pressure and international initiatives including the Stop Pressure Ulcer Day (see Resources) many patients still develop PU needlessly.

There is much debate about how many patients have PU, with current figures suggesting that approximately 18% of hospitalised patients across Europe have them.1 Current NHS Safety Thermometer data suggests a prevalence of around 5% however this excludes category one damage.

Pressure ulcers can be 'counted' in different ways. Prevalence refers to the actual number of patients with pressure ulcers at a given point in time, including those that came into your care with pre-existing PUs. It is therefore not an indicator of the quality of care delivered. It does however give an idea of the workload. Incidence is often seen as an indicator of the quality of care as it only measure new pressure ulcers, ie. those that occur while the patient is in your care. There are various categories of pressure ulcers, as outlined below.2 


Category/Stage I: Nonblanchable Erythema

Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/stage I may be difficult to detect in individuals with dark skin tones. This may indicate “at risk” individuals (a heralding sign of risk).


Category/Stage II: Partial Thickness Skin Loss

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum- filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This category/stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. (*Bruising indicates suspected deep tissue injury.)


Category/Stage III: Full Thickness Skin Loss

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. The depth of a category/stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers. Bone/tendon is not visible or directly palpable.


Category/Stage IV: Full Thickness Tissue Loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/stage IV ulcers can extend into muscle and/or supporting structures (eg. fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. 


Unstageable: Depth Unknown

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore category/stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed.


Suspected Deep Tissue Injury: Depth Unknown

Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.


What causes pressure ulcers?

A recent study3 suggests that there are both direct and indirect risk factors for pressure ulcers plus a range of contributory factors. The direct (and therefore perhaps most important) risks are: 


Poor perfusion.

Skin/PU status.

Indirect factors would include:

Poor sensory perception and response e.g. diabetic neuropathy, lack of sensation following a cerebrovascular accident (CVA).

Moisture on the skin from any source including incontinence, sweat and wound exudate.

Poor nutrition - particularly a low albumin.

In addition older age, infection (particularly with raised body temperature), certain medications, pitting oedema and acute illness are all believed to increase the risk of PU occurring.


The treatment and prevention of pressure ulcers

The most common approach to prevention of pressure ulcers is to identify the key risks and implement a prevention strategy based on them. Many areas choose to use a bundle approach  based around four or five, factors usually known by the acronym SKIN or SSKIN.

The SSKIN bundle targets strategies around:

S - Surface: ensuring the patient is on the correct surface and that it is working properly.

S - Skin: the patient's skin is clean, dry and well hydrated.

K - Keep moving: the patient is encouraged to be active or is repositioned.

I - Incontinence: this is is managed and the patient's skin cared for. 

N - Nutrition: supportive nutrition and hydration are in place.

Tools to support implementation of the SSSKIN bundle can be downloaded free of charge from the Stop The Pressure website (see Resources). 

As device-related pressure ulcers are becoming more frequent, their prevention should not be overlooked within the surface and skin elements.


The role of nurses in treating and preventing pressure ulcers

The nurse is frequently the healthcare professional who sees the patient on a regular basis, therefore one of the main roles is to identify risk and particularly changes in risk status should the patient's condition change, due to either an acute illness or gradual deterioration in a chronic condition. They should then ensure that all relevant healthcare professionals and supporting carers - including family, friends and social care-provided carers - are alerted to the risk status. A comprehensive plan of care should be developed, implemented and regularly evaluated. This can be developed around the SSKIN bundle as described above but should include risk factors specific to that individual patient and their care environment.


Current advice and guidelines

New guidelines for the prevention and management of pressure ulcers have been released by the National Institute of Health and Care Excellence (NICE)6 and there has also been more detailed international guidance released.2 Both sets of guidance focus on risk identification and prevention strategies as discussed throughout this article.

There is little new information regarding the management of pressure ulcers should they occur despite appropriate intervention. There is currently much discussion around the existence of unavoidable pressure ulcers.


Unavoidable pressure ulcers

Unavoidable means that the individual developed a pressure ulcer even though the individual's condition and pressure ulcer risk had been evaluated; goals and recognised standards of practice that are consistent with individual needs has been implemented; the impact of these interventions had been monitored, evaluated and recorded; and the approaches had revised as appropriate.8 

Management of pressure damage should focus on alleviating the cause, ie. remove the source of the pressure whether that be a mattress, chair, wheelchair or device. This may involve implementation of a new piece of equipment, regular repositioning and or considerable patient education and support. The wound should then be managed with appropriate dressing products according the objectives of care and presenting tissue types. Consideration should be given to optimising the patient's potential to heal by ensuring the patient is having adequate food and fluid intake and that medication has been reviewed to ensure they are not having an unnecessary impact on the healing process.



In most instances pressure ulceration is preventable as long as risk is recognised and appropriately managed. Nurses caring for any kind of patients must be aware of the specific risk factors in their patients group and be alert to changes in the patient's health status that may increase their risk. However this is not solely a function of nursing staff. All other healthcare professionals (including general practitioners), social care staff and the patient's informal carers, such as family and friends, should be involved in the prevention of pressure damage.