How to Prevent & Cure
Pressure Ulcers
Home Mobility & Park House
Solutions
Overview
• Pressure Ulcer
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Definition
Causes
Predisposing Risk Factors
Grades
Effects on Patient
• Solutions
– Risk Assessment
– Skin Wound Protocol
Pressure Ulcer
Causes of Pressure Ulcer Development
Pressure
Pressure Ulcer
What is Pressure Ulcer?
• A localized area of cellular damage resulting from:
– Direct pressure: skin and other tissues are directly
compressed between bone and another surface
(bed, chair). Tissue damage will depend on intensity
and duration of exposure to pressure.
– Shearing: tissues are wrenched in opposite
directions, resulting in disruption or angulations of
capillary blood vessels.
– Friction: skin rubs against another surface (sheet)
causing epidermis to be stripped away.
• Also called Pressure Sores, Decubitus Ulcers or
Bed Sores
Pressure Ulcer
Bony Prominences at Risk
Pressure Ulcer
Predisposing Risk Factors
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Level of Mobility
Nutrition
Continence
Medication
Concurrent disease
Age
Pressure Ulcer
Grades of Ulcers
Two Hours …
… That’s what it takes to develop a
pressure ulcer.
Pressure Ulcer
Grades of Ulcers
Grade 1
Epidermis
Dermis
Subcutaneous Fat
Muscle
Bone
Redness that does not
disappear when pressure
is applied
Pressure Ulcer
Grades of Ulcers
Grade 2
Pressure Ulcer
Grades of Ulcers
Grade 3
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Grades of Ulcers
Grade 4
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Grades of Ulcers
Very Fast Process
Grade I: 14 Days
Grade II: 45 days
Very Slow Process
Grade III: 90 days
Grade IV: 120 Days
Pressure Ulcer
Effects on Patient
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Pain
Systemic illness
Reduced self-esteem
Altered body image
Delayed rehabilitation measures
Amputation
Death
Pressure Ulcer
Solution
Pressure Ulcer
Risk Assessment
• Why?
– Because we can prevent Pressure Ulcers
– Because we can cure Pressure Ulcers
• To Whom?
– All person with reduced mobility / activity or sedated
• When?
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Admission
Regular Intervals
Change in patient conditions
During day and night
Pressure Ulcer
Risk Assessment
• Benefits?
– Act as aid-memory
– Target preventive care
– Effective use of scarce resources
– Provide quantifiable data of audit
– Provides objective criteria to base care
pathways
• How?
– Use Risk Assessment Tools
Pressure Ulcer
Risk Assessment Tools
• Braden
• Douglas
• Gosnell
• Knoll
• PSPS (Lowthian)
• Medley
• Norton
• N.P.R.U
• Walsall
• Waterlow
Pressure Ulcer
Skin Wound Protocol
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Pressure Reduction
Pressure Relief
Incontinence Care
Nutrition Consult
Moisturize Skin
Positioning
Wound Care
Pressure Ulcer
Skin Wound Protocol
Pressure Reduction
Pressure Ulcer
Pressure Reduction
• Reduce the intensity of pressure and shear :
Blood irrigation occlusion diminish  O2 flows in tissue
– Intensity is determined by contact surface (mattress
or cushion). When the surface is increased, pressure
is more evenly redistributed decreasing pressure.
– Avoid several tissue layers because they increase the
pressure
– Avoid anything that reduces the size of the pressure
surface (ring cushions)
• Should be combined with scheduled alternated
repositioning of the patient.
Pressure Ulcer
Pressure Reduction
• Pressure Reduction can be done through
specialized mattresses / Cushions
• Static Mattresses are non electric system that
reduces intensity of the pressure and shear by
increasing contact surface
• Overlay is placed over standard mattress and
has the same effect as static mattress
• The nature and composition of the material
modify the form and the consistency of the
mattress that is subject to patient body pressure.
Pressure Ulcer
Pressure Reduction
Different Materials:
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Water
Static Air
Gel
Fiber
Foam
• CMHR: Combustion Modified High
Resilient
• Visco-elastic
Pressure Ulcer
Pressure Reduction
Water Mattress Advantages:
• Cheap
• Distributes weight evenly
Water Mattress Disadvantages:
• A spontaneous or assisted change in the
positioning is more difficult  favours
longer period in the same position 
higher risk of pressure ulcer development.
Pressure Ulcer
Pressure Reduction
Water Mattress Disadvantages:
• Very difficult to position the patient in Lateral
Decubitus @ 30° (this position is recommended
for long stay periods)  Low comfort and
increased pressure  higher risk of pressure
ulcer development.
• Cannot be used on profiling beds (electrical)
because of the weight of the mattress and the
bed inclination
• Cold sensation from the water  patient
discomfort
Pressure Ulcer
Pressure Reduction
Water Mattress Disadvantages:
• Extremely heavy weight  can causes back
injury to carer
• The mattress can break  inundation 
unpleasant situation for both patient and carer.
• Rocking effect  may cause dizziness to
predisposed patients
• Not durable
• Requires a second mattress below
Pressure Ulcer
Pressure Reduction
Static Air Mattress Advantages:
• Easy use: once filled with air, it does not require an
electric pump.
• Heat build up and moisture are greatly reduced, due to
the air holes throughout the mattress.
• Light weight.
• Best in its class for seating (cushions); however should
be thick enough to prevent bottoming effect
Static Air Mattress Disadvantages:
• Contact surface is not increased enough to reduce
pressure.
• Not durable
• Requires a second mattress below
Pressure Ulcer
Pressure Reduction
Gel Mattress Advantages:
• Comfortable
• Viscous gel migrates through sectioned bladders
to relieve pressure around bony prominences.
Gel Mattress Disadvantages:
• Contact surface is not increased enough to
reduce pressure.
• Gel can dissociate and loose all its properties.
• Not durable
Pressure Ulcer
Pressure Reduction
Fiber Mattress advantages:
• High quality patient comfort
• Lasting durability
• Easy Maintenance
• Body is enveloped by the fiber
• Used for very frail bony patients
• Light weight
Fiber Mattress Disadvantages:
• Pressure reducing properties are not enough
• Rocking effect  may cause dizziness to predisposed
patients
• Requires a second mattress below
Pressure Ulcer
Pressure Reduction
Foam Mattress CMHR advantages:
• Longer useful life than non-HR foam
• High tear strength
• Ability of material to revert to its original shape after pressure 
optimal lying comfort
• Easy Maintenance
• More Supple
• Moulds body shape  Maximize weight distribution  Reduce
pressure
• Extremely fire retardant, complies to institutional regulatory
standards
Foam Mattress HR Disadvantages:
• Used for Low to Medium risk patients only
Pressure Ulcer
Pressure Reduction
Foam Mattress Visco-Elastic advantages:
• Best in its class for static mattresses.
• High quality patient comfort
• Lasting durability
• Easy Maintenance
• Moulds the body allowing patient immersion thus
increasing the contact surface and decreasing the
pressure.
• High Memory Foam
Pressure Ulcer
Pressure Reduction
Foam Mattress Visco-Elastic advantages:
• Heat sensitive property allows the top of the
mattress to be more supple whereas the deeper
parts remains firm for a proper support. This
maintains the physiological position of the
patient maximizing the weight distribution.
• Used for Medium to High Risk Patient
Pressure Ulcer
Pressure Reduction
Cover of the mattress is very important and should
provide the following:
• Two way stretch  Reduce friction and sheer
effects.
• Elastic, otherwise it will limit the capacity of the
mattress to reduce pressure
• Vapor Permeable  evacuate heat  patient
comfort
• Fire Retardant  Fire safety  patient safety
Pressure Ulcer
Pressure Reduction
• Water Resistant  Prevent fluid contamination
 patient hygiene & safety
• Concealed Zip Fastening  Prevent fluid
contamination  patient hygiene & safety
• Fully Fitted  moulds to the shape of the bed 
Reduce friction and sheer effects
• Detachable cover  machine washable  easy
to clean  patient hygiene
Pressure Ulcer
Skin Wound Protocol
Pressure Relief
Pressure Ulcer
Pressure Relief
• Purpose is to reduce the duration of
pressure and shear by changing the points
of pressure.
• Pressure Relief can be done in two ways:
– Scheduled alternated positioning
– Specialized mattresses
Pressure Ulcer
Pressure Relief
• Scheduled alternated positioning
– Change the position of the patient in a way that body
prominences at risk (points of pressure) are different.
– Frequency per 24 hours/day, 7 days/week:
Laying Position
• Every two hours if no pressure reduction mattress is used 
Almost impossible to manage.
• Every four hours when a good and appropriate pressure
reduction mattress is used
Seating Position
• Every one hour if no pressure reduction cushion is used
• Every two hours when a good and appropriate pressure
reduction cushion is used
Pressure Ulcer
Pressure Relief
• Specialized Mattresses are electric system that
reduces the duration of the pressure and shear.
• Consist of an inflatable mattress and an electric
pump.
• Overlay is placed over standard mattress and
has the same effect as an active mattress.
• The cells / compartments of the mattress inflates
and deflates in alternation.
• The form of the mattress, that is subject to
patient body pressure, changes due to external
factors (air pump).
Pressure Ulcer
Pressure Relief
• Differentiation points:
– Pump characteristics
– Availability of an “intelligent” feed-back
system
– Diameter of the cells
– Distinct compartments
– Additional facilities
– Cell structure
– Cover
Pressure Ulcer
Pressure Relief
• Pump characteristics:
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Quiet
Lightweight and Compact
Clear user instructions
Snap fit connectors, color coded
Adjustable pressure control (better if it is automatic)
Audio – visual alarms
Different settings: Pulsate, Therapy & Static
Comfort control
Pressure Ulcer
Pressure Relief
• Pump characteristics:
– Equalized cell pressure when mattress is
disconnected from power unit (transport /
power failure)
– Duration of the pressure: 9 to 10 minutes
cycle.
– External fusibles to protect the pump from
current fluctuations.
Pressure Ulcer
Pressure Relief
• Availability of an “intelligent” feed-back
system :
– Senses movement of patient
– Automatic adjustment to individual patient
weight and position
– Optimum pressure is delivered at all times
regardless of body mass.
– Back-Raise sensor for semi-recumbent
position  push more air in torso section for
better support  prevents bottoming-out
Pressure Ulcer
Pressure Relief
• Diameter of the cells :
– Small cells (less then 10 cm) even when
inflated to the maximum, do not allow the
body to elevates enough above the deflated
cells.
– Cells larger then 10 cm are recommended.
Pressure Ulcer
Pressure Relief
• Distinct compartments:
– Individual cells  easy replacement
– Tri zonal: comfort for head, torso & heel
– Sloping heel section
• Additional Facilities:
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Timed static facility
Static facility for fast transfer
CPR facility near head section for faster deflation
Intubation's facility
Pressure Ulcer
Pressure Relief
• The cell structure - number and form:
– Double layer cell structure is more efficient then single
layer.
– Cells are linked between each others by series of 3 and
same cycle is applied for both layers simultaneously:
1st max. inflation, 2nd half inflation, 3rd total deflation
1st half inflation, 2nd max. inflation, 3rd half inflation
1st total deflation, 2nd half inflation, 3rd max. inflation
Pressure Ulcer
Pressure Relief
• Cover :
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Two way stretch  Reduce friction and sheer effects.
Elastic  maintain reduction property of mattress.
Vapor Permeable  evacuate heat  patient comfort
Fire Retardant  Fire safety  patient safety
Water Resistant  Prevent fluid contamination  patient
hygiene & safety
Concealed Zip Fastening  Prevent fluid contamination 
patient hygiene & safety
Fully Fitted  moulds to the shape of the bed  Reduce friction
and sheer effects
Detachable cover  easy cleaning
Hoses covered  as per disinfections properties
Pressure Ulcer
Pressure Relief
• Special mattresses:
– Fluidized Air: Mattress is composed of silicom
particles inside a synthetic cover. When hot
air is injected the silicon particles liquefies.
– Low air-loss: Reduce humidity build-up to to
the air-loss.
Pressure Ulcer
Pressure Relief
Fluidized Air Advantages:
• The body is totally immersed in the mattress which
maximizes the contact surface between the body and the
mattress
• Excellent system for treating burns or wounds with high
exudates.
Fluidized Air Disadvantages:
• Very expensive
• Extremely difficult to clean
• Cannot be moved from 1 patient to another before a
special cleaning process has taken place.
Pressure Ulcer
Pressure Relief
Low Air loss Advantages:
• Designed to provide very high degree of comfort
• Constant air flow will help dry up wounds
• Separate mattress system can be easily moved
from patient to patient and from bed to bed.
• Easy to clean and decontaminate
Pressure Ulcer
Skin Wound Protocol
Incontinence Care
Pressure Ulcer
Incontinence Care
• Clean skin at time of soiling
• Provide quick drying surface (under pads)
to the skin.
• Avoid hot water and too much soap while
bathing.
Pressure Ulcer
Skin Wound Protocol
Nutrition Consult
Pressure Ulcer
Nutrition Consult
• Diet should have adequate calories and
protein, vitamins and mineral
supplements.
• Consult your dietician and doctor.
• There is no direct link between bad
nutrition and pressure ulcer prevention
however nutrition optimization ameliorates
the general condition of the patient and
helps the cicatrisation process.
Pressure Ulcer
Skin Wound Protocol
Moisturize Skin
Pressure Ulcer
Moisturize Skin
• Maintain good hygiene
• Wash with mild soap and warm water,
rinse well and pat dry carefully and gently.
• Use moisturizers for dry skin
• Minimize environmental factors leading to
dry skin (Low humidity, cold air)
• Do not massage skin over bony parts of
the body (can damage tissue)
Pressure Ulcer
Skin Wound Protocol
Positioning
Pressure Ulcer
Positioning
• The intensity of the pressure is determined
by the weight of the patient, his positioning
and the hardness of the material he is
seated in.
• The contact surface depends on the
positioning: Surface  redistribution of
pressure Pressure
Pressure Ulcer
Positioning
• Some facts:
– In laying position: Avoid bottoming effect where the
patient is not sustained by the mattress but lies
directly on the sub-adjacent surface, specially for
obese patients.
– With a simple manual verification, we should not
feel patient body.
Pressure Ulcer
Positioning
• Some facts:
– In laying position: when the bed head is
elevated, the pressure and shear effects
increase.
– In seating position, the weight is
redistributed in a small surface: more
pressure then laying position.
– In seating position, a lateral or vertical
inclination increases the pressure.
Pressure Ulcer
Positioning
• Dorsal Decubitus
– Head and legs of the bed are elevated 30°:
maximum reduction of pressure and shear.
– Preferred positioning for long periods.
Pressure Ulcer
Positioning
• Lateral Decubitus
– Body forms a 30° angle with the mattress aided by a 30° cushion
– The sacrum should not be under pressure.
– Above leg is positioned behind the other one, tilted 30° at the
level of the hip and 35° at the level of knee.
– Positioning can be made more comfortable with cushions
– Use of inflatable cushions is not
recommended due to the effect of shear.
Pressure Ulcer
Positioning
• Alternated positioning
Mobilisation
alternée
– Use as often as possible
Dorsal Decubitus
positioning
– Alternate with lateral
Decubitus positioning
• When using appropriate
pressure reducing
mattress, the schedule
can be every 4 hours
instead of 2 hours.
12
11
1
10
2
3
9
4
8
5
7
6
L
30°
R
30°
Semi-Fowler 30° - 30°
30°
Lat. 30°
Nom
:
Pressure Ulcer
Positioning
• Seating position in bed
– Limit seating positions in bed because it is the cause
of shearing.
– Preferred position is 60° but should be limited in
duration.
– Use this position only for eating time.
Pressure Ulcer
Positioning
• Ventral Decubitus
– Should be used with soft mattress for comfort
– To prevent pressure on feet, either place a cushion or remove
end of bed and slide down patient so that feet are outside
mattress.
– Should observe pressure points: shoulder, thorax, basin, knees,
feet, ears.
Décubitus ventral
Pressure Ulcer
Positioning
– Heel
Pressure Ulcer
Positioning
• Seating
– Slight dorsal inclination, legs resting on
support and heels free of pressure
– In case dorsal inclination is not possible,
straight seating with both feet on floor
Pressure Ulcer
Positioning
• Seating
– Limit the duration of seating position: time spent on
chair should be less then time spent in fauteuil which
is less then the bed.
– Armchair help stabilize the positioning of the person.
– Avoid lateral and vertical sliding from chair.
– Make sure that the person is well seated to provide
optimum contact surface.
– Cushion and backs help to keep a right positioning.
The type should be studied case by case.
Pressure Ulcer
Skin Wound Protocol
Wound Care
Pressure Ulcer
Wound Care
- Debride – Ask your doctor
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Surgical: most rapid, recommended for large necrotic areas.
Mechanical: hydrotherapy, wound irrigation
Enzymatic: collagenase to slow infection if present.
Autolytic: via enzymes in wound fluid (very slow)
- Pick a dressing (must provide a-moist wound healing)
- Transparent semi permeable films (eg Opsite, Tegaderm) for
Grade I & II
- Hydrocolloids (e.g. DuoDerm, Comfeel, Restore) for non infected
Grade II & III
- Saline soaked gauze (covered by occlusive wrap) gently pack dead
space for Grade II to IV
- Alignates: (eg. CalciCare, Kaltostat) for +++ exudates
Pressure Ulcer
Wound Care
- Watch for infection and treat - Ask your doctor for
proper treatment.
- Use dry lubricants (cornstarch) or protective
coverings to reduce friction injury.
Pressure Ulcer
Healing signs
- The pressure ulcer will get smaller
- Pinkish tissue usually starts forming along the edges
of the sore.
- Smooth or bumpy surfaces of new tissue
- Some bleeding may be present which shows good
blood circulation.
Pressure Ulcer
Any Questions
Thank You for Your Time