Introduction to
Pressure Ulcers
Impacts of Pressure Ulcers
Pressure ulcers affect quality of life for
patients:
• Limit activity.
• Are painful.
• Require time-consuming
treatments and dressing
changes.
• Can pose a risk of
infection and sepsis.
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Presentation Addresses:
• What is a pressure ulcer (the 2007
definition)
• Risk factors
• General guidelines for assessment
• Staging pressure ulcers
• Differentiating pressure ulcers from
other wounds/ skin conditions
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Objectives
• Define pressure ulcer.
• Identify key components of pressure
ulcer assessment.
• Describe major characteristics of the
pressure ulcer stages.
• Differentiate pressure ulcers from other
wounds/ skin conditions.
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CMS Pressure Ulcer Definition
CMS has adapted the NPUAP 2007
definition for a pressure ulcer:
A pressure ulcer is a localized injury to
the skin and/or underlying tissue
usually over a bony prominence, as a
result of pressure or pressure in
combination with shear and/ or friction.
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Pressure Ulcer Risk Factors
• Immobility, decreased functional ability
• Co-morbid conditions (ESRD, thyroid)
• Diabetes
• Drugs such as steroids
• Impaired diffuse or localized blood flow
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Pressure Ulcer Risk Factors, Cont.
• Exposure to moisture, urinary and fecal
incontinence
• Under-nutrition, malnutrition, hydration
deficits
• Patient refusal of care and treatment
• Cognitive impairment
• Healed pressure ulcer that has closed
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Pressure Ulcer Assessment
• Staging
o Categorizing pressure ulcers in terms of depth
of tissue loss
o Stages 1-4 and Unstageable
• Distinguishing pressure ulcers from
wounds/skin conditions
o Imperative to differentiate the etiology for
proper treatment and management of wound.
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General Assessment Guidelines
• Review the medical record.
• Examine the patient.
o Perform a head-to-toe, full body skin
assessment.
o Focus on bony prominences and pressurebearing areas.
o Use visual inspection and palpation.
o Ensure a comprehensive assessment.
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General Assessment
Guidelines, Cont.
• Consult with direct care
staff on all shifts.
• Assess for the presence
of pressure ulcers during
assessment period.
• Document assessment
findings in patient’s
medical record.
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Staging
Pressure Ulcers
Staging Definitions
• CMS has adapted the 2007 NPUAP
definitions for categories of staging.
• Resource: www.npuap.org
• Free diagrams of
ulcer stages can
be downloaded for
educational use.
Reproduced with permission
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Stage 1 Pressure Ulcers
Stage 1 Pressure Ulcer
• Intact skin with non-blanchable redness of a
localized area, usually over a bony prominence.
• Darkly pigmented skin may not have visible blanching.
• Color may differ from the surrounding area.
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Assessing Stage 1 Pressure Ulcers
• Perform a head-to-toe, full body skin
assessment.
• Focus on bony
prominences and
pressure-bearing areas:
o Sacrum
o Heels
o Buttocks
o Ankles
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Assessing Stage 1 Pressure Ulcers2
• Consider where patient spends time.
• Check any reddened areas for ability
to blanch.
o Firmly press finger into tissue, then remove.
o Non-blanchable: no loss of skin color or
pressure-induced pallor at the compressed
site
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Assessing Stage 1 Pressure Ulcers3
• Search for other areas of skin that differ
from surrounding tissue.
o Painful
o Firm
o Soft
o Color
change
o Warmer/ cooler
• Assessment to determine staging should
be comprehensive.
• Stage 1 ulcers may be difficult to detect
in individuals with dark skin tones.
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Differentiating Stage 1
Pressure Ulcers
• Differentiate Stage 1 pressure ulcer and
suspected deep tissue injuries (sDTIs).
• Differentiate Stage 1 pressure ulcers and
moisture-associated skin damage (MASD).
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Is This a Stage 1 Pressure Ulcer?
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Stage 2 Pressure Ulcers
Stage 2 Pressure Ulcer
• Partial thickness loss of dermis
presenting as:
o Shallow open
ulcer
o Red or pink
wound bed
o Without
slough
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Stage 2 Pressure Ulcer, Cont.
• May also present
as an intact or open/
ruptured blister
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Assessing Stage 2
Pressure Ulcers
• Perform a head-to-toe, full body skin
assessment.
• Focus on bony prominences and pressurebearing areas.
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Assessing Stage 2
Pressure Ulcers, Cont.
• Examine the area adjacent to or surrounding
any intact blister for evidence of tissue damage.
o Color change
o Tenderness
o Bogginess or firmness
o Warmth or coolness
• If the surrounding or adjacent soft tissue does
NOT have the evidence of tissue damage, it is a
Stage 2 pressure ulcer.
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Differentiating
Stage 2 Pressure Ulcers
• Confirm that the wound being assessed
is primarily related to pressure.
o Rule out other conditions.
o Do not identify a wound as a pressure
ulcer if pressure is not the primary
cause.
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Differentiating
Stage 2 Pressure Ulcers2
• Differentiate Stage 2 pressure ulcers and
deep tissue injuries.
• Stage 2 ulcers will generally lack the surrounding
characteristics (color change, tenderness,
bogginess, etc.)
found with a deep
tissue
injury.
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Differentiating
Stage 2 Pressure Ulcers3
• Do not identify the following as pressure
ulcers:
o Skin tears
o Tape burns
o Moisture associated Skin Damage from
incontinence
o Excoriation
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Is This a Stage 2 Pressure Ulcer?
1. What steps should you
take to assess this?
2. Is this a Stage 2 pressure
ulcer?
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Is This a Stage 2 Pressure Ulcer?
1. What steps should you take to assess this?
2. Is this a Stage 2 pressure ulcer?
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Is This a Stage 2 Pressure Ulcer?
1. What steps should you take to assess this?
2. Is this a Stage 2 pressure ulcer?
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Stage 3 and 4
Pressure Ulcers
Stage 3 Pressure Ulcer
• Full thickness tissue loss
• Subcutaneous fat may
be visible but bone,
tendon or muscle
is not exposed.
• Slough may be present
but does not obscure the
depth of tissue loss.
• May include undermining and tunneling
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Stage 4 Pressure Ulcer
•
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.
•
Depth varies by anatomical location (bridge of nose,
ear, occiput, and malleous ulcers can be shallow).
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Distinguishing Stage 3 and 4
Pressure Ulcers
• Stage 3: Bone, tendon or muscle is
not visible or palpable.
• Stage 4: Bone, tendon or muscle is
visible or palpable.
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Reverse Staging
• Do not reverse stage.
o Example: Over time, a Stage 4 pressure
ulcer has been healing. Previously,
reverse staging was permitted. Once the
pressure ulcer reached a depth consistent
with Stage 2 pressure ulcers, could be
identified as Stage 2.
o Currently, it is required that it continue to
be documented as a Stage 4 until
completely healed.
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Scenario:
Staging the Pressure Ulcer
• A pressure ulcer described as a Stage 2
was documented in the patient’s medical
record at the time of admission.
• On a later assessment, the wound is noted
to be a full thickness ulcer with no exposure
of bone, tendon or muscle.
• What is the stage of the ulcer now?
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Unstageable Pressure
Ulcers
Unstageable Pressure Ulcers
• Three types to differentiate:
o Unstageable due to Non-Removable
Device or Dressing
o Unstageable due to Slough and/or
Eschar
o Unstageable due to Suspected Deep
Tissue Injury (sDTI)
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Unstageable
Non-Removable Device
• Ulcer covered with eschar under plaster cast
• Known but not stageable because of the nonremovable device
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Unstageable
Non-Removable Dressing
• Known but not stageable because of
the non-removable dressing
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Unstageable
Slough and/or Eschar
• Known but not stageable due to coverage of
wound bed by slough and/or eschar
• Full thickness tissue
loss
• Base of ulcer covered
by slough (yellow, tan,
gray, green or brown)
and/or eschar (tan,
brown or black) in the
wound bed
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Unstageable
Suspected Deep Tissue Injury
• Related to damage of underlying soft tissue from
pressure and/or shear
• Deep tissue injuries can
indicate severe damage.
Identification and
management imperative.
• Localized area of
discolored (darker
than surrounding
tissue), intact skin
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Unstageable
Suspected Deep Tissue Injury
• Area of discoloration 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.
• Identify as Unstageable due to sDTI when
wound related to pressure presents with intact
blister and surrounding or adjacent soft tissue
has characteristics of deep tissue injury.
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Scenario:
Staging the Pressure Ulcer
• Ms. James was admitted with one small
Stage 2 pressure ulcer.
• Despite treatment, it is not improving.
• The wound bed is covered with slough.
• What is the stage of the ulcer now?
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A Final Word
• Quality health care begins with
prevention of and assessment for
pressure ulcers.
• Clearly document assessment findings
in the patient’s medical record.
• Track and document appropriate wound
care planning and management.
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Pressure Ulcer
Staging Quiz
Pressure Ulcer Quiz #1
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #2
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #3
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #4
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable - Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #5
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #6
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #7
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #8
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable - Slough or Eschar
• Unstageable - sDTI
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Pressure Ulcer Quiz #9
• Stage 1
• Stage 2
• Stage 3
• Stage 4
• Unstageable - Slough or Eschar
• Unstageable - sDTI
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Differentiating
Pressure Ulcers
from Other
Wounds/ Skin Conditions
Importance of Wound
Differentiation
• There are a variety of other wound types in
addition to pressure ulcers.
• Differentiating wounds requires knowledge,
experience, patient history/ events, and
interdisciplinary collaboration.
• A comprehensive assessment is needed.
• Differentiating the etiology of the wound is
essential to determine and direct the proper
treatment and management of the wound.
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Wounds and Skin Conditions
• Venous and Arterial Ulcers
• Diabetic Foot Ulcers
• Open Lesions Other than Ulcers, Rashes, Cuts
• Surgical Wounds
• Burns
• Skin Tears
• Moisture-Associated Skin Damage (MASD)
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Venous Ulcers
• May be result of minor trauma.
• Usual location is lower
leg area or medial
or lateral malleolus.
• Characterized by:
o Irregular wound edges
o Hemosiderin staining
o Leg edema
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Arterial Ulcers
• May be result of minor trauma.
• Usual location:
o Toes
o Top of foot
o Distal to medial
malleolus
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Characteristics of
Arterial Ulcers
• Necrotic tissue or pale pink wound bed
• Diminished or absent pulses
• Trophic skin changes:
o Dry skin
o Loss of hair
o Brittle nails
o Muscle atrophy
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Diabetic Foot Ulcers
• Caused by the neuropathic and small blood
vessel complications of diabetes.
• Usual location: Over plantar (bottom) surface
of foot on load bearing areas
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Characteristics of
Diabetic Foot Ulcers
• Usually deep, with necrotic tissue, moderate
amounts of exudate and calloused wound
edges
• Very regular in shape; wound edges are
even, with a punched-out appearance
• Even though patient has neuropathy, may have
pain
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Open Lesions Other
than Ulcers, Rashes, Cuts
• Typically, skin ulcers that
develop as a result of
diseases and conditions
such as syphilis and
cancer.
• Patient history
is helpful to identify
wound etiology.
• Type of skin condition
will determine location.
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Surgical Wounds
• Healing or non-healing, open or closed surgical
incisions
• Skin grafts
• Drainage sites
• Surgical flap to repair a pressure ulcer
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Burns
• Skin and tissue injury caused by heat or
chemicals.
• Patient history of events is helpful to differentiate
etiology and type of burn.
• May be in any stage of healing.
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Skin Tears
• Are acute traumatic wounds.
• May occur as a result of shear, friction or
trauma to the skin.
• The epidermis separates from the dermis.
• Usually occur on the extremities of older
adults.
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Characteristics of Skin Tears
• Often painful
• Part or all of epidermis (skin flap may be
present)
• Shallow wounds
• Bleeding may be present
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Moisture-Associated Skin Damage
• Occurs with sustained
exposure to moisture
• Several etiologies
associated with MASD
o Example: urinary or
fecal incontinence
• Location of MASD
associated with its
etiology
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Characteristics of MoistureAssociated Skin Damage
• Inflammation and erosion of the skin
• Very diffuse, with reddened, superficial area(s)
• Initially superficial but further damage may result
from factors such as pressure
• May have superimposed fungal infection (on top
of MASD)
• No necrotic tissue
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Assessing Wounds/
Skin Conditions
• Review the medical record.
o Skin care flow sheet or other skin tracking form.
o Treatment records and orders for documented
treatments.
• Speak with direct care staff and treatment nurse.
o Confirm conclusions from medical record review.
• Examine the patient.
o Determine if ulcers, wounds, or skin problems are
present.
o Observe skin treatments.
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Scenario #1
What Type of Skin Condition?
• A patient has diabetes mellitus.
• He presents with an ulcer on the heel
that is due to pressure.
• Is this a pressure ulcer or another skin
condition?
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Scenario #2
What Type of Skin Condition?
• A patient is readmitted from the
hospital after flap surgery to repair
a sacral pressure ulcer.
• Is this a pressure ulcer or another
skin condition?
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Wound Quiz
Wound Quiz #1
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Wound Quiz #2
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Wound Quiz #3
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Wound Quiz #4
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Wound Quiz #5
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Wound Quiz #6
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Wound Quiz #7
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Wound Quiz #8
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Wound Quiz #9
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Wound Quiz #10
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Wound Quiz #11
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