Pressure Ulcers

Hospital-acquired pressure ulcers (HAPU) affect an estimated 2.5 million annually.  Not only do they cause pain, premature mortality, and an increased length of stay, they are expensive; a single full-thickness pressure ulcer can cost up to $70,000 to treat.  Treating pressure ulcers cost an estimated $11 billion annually.

Although prevention and treatment options have improved, they are still an issue in healthcare.

What Causes Pressure Ulcers?

Pressure ulcers, often called bedsores, are defined by Mayo Clinic as, “…injuries to skin and underlying tissue resulting from prolonged pressure on the skin.”  Though they can occur anywhere, they are most likely to occur on a bony prominence, such as a heel, hip, or tailbone.

Pressure ulcers occurs because pressure is exerted from a surface onto the skin; this pressure reduces the flow of the blood.  Proper blood flow is essential as blood provides oxygen and nutrients; without oxygen and nutrients, tissue death can occur.

Pressure ulcers can also occur due to friction; friction occurs when the skin rubs against sheets or clothing.  Similar, shear occurs when two surfaces move in the opposite direction; for example, this can occur when getting a “boost” in bed; the tailbone may move higher in the bed, while the skin stays in the sample place.

Common pressure ulcer sites include:

  • The tailbone and the buttocks
  • The back of the arms and legs when the hit the chair
  • Shoulder blade and spine
  • The back and the side of the head
  • The hips
  • The heels and ankles

Pressure ulcers seem to occur very quickly; symptoms will vary depending on the severity, but may include:

  • Changes in the color and texture of the skin
  • Swelling
  • Pus-like drainage
  • Tenderness to the skin
  • Temperature changes of the skin

Stages of Pressure Ulcers

When a wound is detected, it should be staged; staging allows for the proper treatment.  According to Johns Hopkins Medicine, an assessment of the wound is necessary in order to stage it appropriately; “Wound assessment includes: location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection.”

The class or the stage of the wound is based on classification devised by the National Pressure Ulcer Advisory Panel (NPUAP).  The stages are as follows:

  • Stage I: the skin is intact with non-blanchable redness in a localized area; this is generally over a bony prominence.  The color typically differs from surrounding areas.
  • Stage II: there is a partial thickness loss of the skin which presents as a shallow ulcer, red or pink in color.  It may also present as an intact or open serum-filled blister.
  • Stage III: considered full-thickness skin loss, fat may be visible, but bone, tendon, and muscle aren’t exposed.  Slough may be present, but it is possible to view the depth of the wound. There may be tunneling present.
  • Stage IV: full-thickness skin loss with muscle, bone, and tendon exposed.  Slough or eschar may be present, as well as tunneling.
  • Unstageable: full-thickness skin loss with green, brown, yellow, tan, or gray slough is present as well as brown, black, or tan eschar in the wound bed.  This makes it difficult or impossible to stage the wound.
  • Suspected deep tissue injury: a purple localized discolored area that is intact due to damage to underlying tissue from pressure and/or shear.  

Classifying the wound gets even more complicated; a wound care nurse or provider must take measurements of the wound’s length, depth, and width, and take note of tunneling.  

She must note the tissue that is present in the wound bed:

  • Necrosis/eschar: brown, black, or tan tissue that adheres to the wound bed; may be harder or softer its surrounding tissues
  • Slough: soft, moist tissue that is present in the wound bed in strings or clumps; it may be yellow, tan, white, or green.
  • Granulation: healthy tissue that is pink or red, granulation is regenerating tissue comprised of new blood vessels, collagen, and fibroblasts.  
  • Epithelium: new pink skin that grows in from the edges of the wound

Other factors that must be assessed include exudate, odor, the perimeter of the wound, pain, and presence of infection.

Who is at Risk for Pressure Ulcers?

Those who are at the highest risk for development of pressure ulcers are those with limited mobility.  For example, a person who is unable to change positions easily in their bed or chair is at a high risk for developing a pressure ulcer.

Other risk factors for pressure ulcers include:

  • Being immobile.  Limited mobility greatly increases the risk for pressure ulcers.
  • Poor nutrition and hydration.  Adequate intake of fluids, macronutrients, vitamins, and minerals keeps skin healthy and prevents breakdown.
  • Certain medical conditions.  Certain conditions can reduce blood flow, such as diabetes and vascular disease.  Without proper blood flow, the risk of pressure ulcers increases.
  • Lack of sensory perception.  Certain conditions can reduce sensory perception, such as spinal cord injuries and neurological disorders.  With a lack of perception comes a reduced ability to sense warning signs about a need to change position.

Prevention of Pressure Ulcers

Much money is spent on treating ulcers.  As such, it is better to prevent pressure ulcers from occurring in the first place.

For patients who have limited mobility, spend a lot of time in a bed or their chair, or have any of the risk factors discussed above, following these tips can help to prevent pressure ulcers:

  • When in a wheelchair, adjusting the patient’s position every 15 minutes
  • When in bed, turning the patient’s position every two hours
  • Inspect the skin daily
  • Ensure that the patient is receiving proper nutrition
  • Quitting smoking
  • Promote exercise, even if the patient limited to their bed or chair; proper exercise promotes circulation

New Treatments

We’ve come a long way since placing a traditional dressing on a pressure ulcer and hoping it heals.  Here are a couple new treatments in the news:

  • DERMATAC tape has recently received FDA clearance; this tape is a negative pressure wound therapy (NPWT) drape that adheres tightly to a wound for 48 to 72 hours, even in uneven areas.  It creates a tight seal. This NPWT is thought to be less restrictive, less painful, and requires less training to providers.
  • Researchers at Binghampton University discovered that wounds with biofilm often require removal of pyruvate in order to disassemble the biofilm structure and allow the biofilm to be susceptible to antibiotics.  When using novel therapies that treat pyruvate as an adjunct therapy, treatment of wounds was much more successful than treating wounds alone.


Bedsores. (2018, March 9). Retrieved May 16, 2019, from

Binghamton University. (2019, April 23). New dispersion method to effectively kill biofilm bacteria could improve wound care. ScienceDaily. Retrieved May 17, 2019 from

By the Numbers: CHPSO Pressure Injury Data. (2017, August 4). Retrieved May 16, 2019, from

DeMarco, S. (n.d.). Wound and Pressure Ulcer Management. Retrieved May 16, 2019, from

KCI Announces Significant Advancement in Negative Pressure Wound Therapy Drape Technology. (2019, May 16). Retrieved May 17, 2019, from

Nordqvist, C. (2017, December 22). Bed sores or pressure sores: What you need to know. Retrieved May 17, 2019, from

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