British Geriatrics Society
Best Practice Guide
Pressure Ulcers
1. Executive Summary
Pressure ulcers are an unwanted complication of illness, severe physical disability or
increasing frailty. They are caused by pressure and/or shear forces over a bony prominence
in the presence of a number of risk factors, the most important of which is immobility. Data on
older adults from the UK General Practitioner Research Database identified a pressure ulcer
incidence of 1.61%. A number of medical conditions such as chronic obstructive pulmonary
disease; cerebro-vascular accident; diabetes mellitus; hip fracture and hip surgery have been
significantly associated with pressure ulcers. Geriatricians thus have an important role to play
in the prevention and management of pressure ulcers through and awareness and
understanding of current best practice.
It has to be accepted that it is not possible to prevent all pressure ulcers, but with appropriate
care, the majority can be prevented. Prevention strategies need to address the specific risk
factors identified in the initial assessment. The commonest strategies are:
 Pressure relief by means of repositioning and/or the use of pressure redistributing
equipment
 Consideration of the needs of patient when seated in relation to pressure relief
 Improvement of nutritional status
 Skin care including on-going monitoring of skin status and any indications of pressure
damage.
Many of the strategies used for pressure ulcer treatment are the same as those employed for
pressure ulcer prevention, although they may be more intensive than those used in
prevention. Assessment of the pressure ulcer should include:
 Category – shows severity
 Size
 Position on the body – may affect dressing selection
 Level of exudate – will affect dressing selection and frequency of dressing change
 Pain assessment – many ulcers are painful for the patient
Healing may not be a fast process, but generally as long as the patient has adequate
pressure redistribution, good nutrition and appropriate wound management, the ulcer will heal
in most instances.
Geriatricians will encounter individuals at risk of pressure ulceration as well as those with
established pressure ulceration on a regular basis. As part of Comprehensive Geriatric
Assessment and MDT working they are best placed to manage such individuals appropriately.
Additionally, familiarity with risk stratification scales and relevant, often local, guidelines and
policies will prove invaluable adjuncts to optimal management.
2. Introduction
Pressure ulcers are an unwanted complication of illness, severe physical disability or
increasing frailty. They are caused by pressure and/or shear forces over a bony prominence.
There are a number of risk factors associated with pressure ulceration, the most important of
which is immobility. Additional risk factors include poor nutritional status, loss of sensation,
poor perfusion and alterations to intact skin, possibly due to a previous history of pressure
ulcers. Furthermore a number of medical conditions were found to be significantly associated
1
with pressure ulcer development including: Alzheimer’s disease; congestive heart failure;
chronic obstructive pulmonary disease; stroke; diabetes mellitus; deep venous thrombosis;
hip fracture; hip surgery; limb paralysis; lower limb oedema; malignancy; Parkinson’s disease;
rheumatoid arthritis; and urinary tract infections. Pressure ulcers have their highest
prevalence amongst frailty, and Geriatricians thus have an important role to play in the
prevention and management of pressure ulcers through and awareness and understanding of
current best practice.
There are no published national audits of the prevalence of pressure ulcers in the UK. In the
last decade, surveys in other countries found a prevalence in the range of 10-22% of inpatients. The European Pressure Ulcer Advisory Panel published a pilot survey in 5 European
Epidemiological studies in 2005, including over 2500 patients from 15 hospitals in the UK, and
found a UK prevalence of 23%, or 13.9% if only including Category 2 or above ulcers
(Vanderwee). Data on older adults from the UK General Practitioner Research Database
identified a pressure ulcer incidence of 1.61%.
In spite of this huge prevalence and the lack of national audit data, the National Outcomes
Framework for 2012/13 has defined 4 avoidable harms, namely category 2-4 pressure ulcers,
medication errors, VTE and Healthcare associated infections within the NHS Safety
Thermometer CQUIN. This will provide new incentives to reduce pressure ulcer incidence.
3. Definitions / Terminology
The following definition is the most recent and developed for international guidelines by the
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel
(NPUAP/EPUAP, 2009) in a joint collaboration.

A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination with shear. A
number of contributing or confounding factors are also associated with pressure
ulcers; the significance of these factors is yet to be elucidated.
This pressure ulcer classification is used widely across the UK. The term category, rather
than grade or stage, is now preferred.
Category I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Category 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 or serosanginous filled blister.
Category III: Full thickness skin loss
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.
Category IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be
present.
The additional category of unstageable is also recommended by the Tissue Viability Society
for reporting systems within England (TVS, 2012).
Unstageable/ Unclassified: Full thickness skin or tissue loss – depth
unknown
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough
(yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed.
2
4. Health Policy and Guidance
There are numerous policy documents and guidelines in relation to pressure ulcers.
 Quality Improvement Productivity and Prevention (QIPP) in England:
http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPPworkstreams/DH_11
5447
 Health Improvement Scotland Best Practice Statement:
http://www.healthcareimprovementscotland.org/previous_resources/best_practice_st
atement/prevention_and_management_of_p.aspx
 Skin Bundle in Wales:
http://www.1000livesplus.wales.nhs.uk/opendoc/179648




NICE Pressure Ulcer Guidelines:
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10972
Clinical Practice Guidelines for the Prevention and Treatment of Pressure Ulcers:
http://www.epuap.org/guidelines/
National Patient Safety Agency: http://www.npsa.nhs.uk/corporate/news/nhs-toadopt-zero-tolerance-approach-to-pressure-ulcers/?locale=en
NHS Commissioning for Quality and Innovation Payment Framework (CQUIN):
http://www.institute.nhs.uk/commissioning/pct_portal/cquin.html
5. Pressure Ulcer Prevention
It has to be accepted that it is not possible to prevent all pressure ulcers, but with appropriate
care, the majority can be prevented. At a very simple level, prevention means identifying
those at risk and instigating appropriate prevention strategies according to individual need.
However, it is not always straightforward to recognise those at risk. A number of risk
calculators are available for use, but they all have limitations and so produce false positives
(those deemed to be at risk who do not get a pressure ulcer) or false negatives (those whose
score says they are not at risk but who develop pressure damage). NPUAP/EPUAP (2009)
recommend that risk assessment should include a comprehensive skin assessment and
clinical judgement as well as using a risk calculator. Skin assessment is often poorly done,
but is most important to identify potential areas of vulnerability.
Prevention strategies need to address the specific risk factors identified in the initial
assessment. The commonest strategies are:
 Pressure relief by means of repositioning and/or the use of pressure redistributing
equipment
 Consideration of the needs of patient when seated in relation to pressure relief
 Improvement of nutritional status
 Skin care including on-going monitoring of skin status and any indications of pressure
damage.
Pressure relief is the most important prevention strategy and traditionally was achieved by the
use of ‘2 hourly turning’. These days a wide range of pressure redistributing equipment is
available and has almost replaced repositioning of patients. This is unfortunate as
repositioning is important for more than pressure relief. All hospital beds have a high
specification foam mattress as a minimum. If a patient requires a mattress with greater
pressure relief then alternating air overlays or mattresses are generally available. These
systems have a series of cells which alternately inflate and deflate and have varying levels of
sophistication. If a patient is difficult to move or only able to lie in one position then use of a
low air loss bed may beneficial. This support system has an integral bed-frame and mattress
which is composed of a series of large cells filled with air. The air is slowly ‘lost’ through the
cell walls and replaced via the pump resulting in very low pressures in the cells so that the
patient lies in rather than on the mattress.
3
It is an important aspect of care for elderly patients to sit out of bed. However, there are a
number of aspects to consider in relation to pressure ulcer prevention. It is important that
whenever possible patients should be seated in a position that allows them to maintain
function as well as reducing pressure and shear. This may require the use of a footstool or
foot rest to ensure that feet are not left dangling if they do not reach the floor. Patients should
not be left sitting in a chair for long periods of time without pressure relief. Although labour
intensive, encouraging patients to lie on the bed for a short rest after lunch is a simple way of
ensuring they do not sit for too long at a time.
Assessment of nutritional status should be part of the routine care of any patient. A UK survey
of 11,278 people in hospitals, care homes and mental health units found 28% of hospital
patients and 30% of care home residents to be malnourished (Russell & Elia, 2007). It is well
recognised that the elderly are vulnerable to poor nutrition (Guigoz et al, 2002; Cereceda et
al, 2004). The International Pressure Ulcer Guidelines recommend that any patient who is
recognised to be poorly nourished and at risk of pressure ulceration should be referred to a
dietician (NPUAP/EPUAP, 2009). They also recommend that patients who are both at
nutritional risk and pressure ulcer risk should be offered a minimum of 30-35 kcal per kg body
weight per day, with 1.25-1.5g/kg/day protein and 1ml of fluid intake per kcal per day. The use
of nutritional supplements between meals may be a useful way of increasing intake.
Skin assessment and skin care is often a neglected area of patient care. Yet skin assessment
is the only way of identifying signs of tissue damage. It should be an ongoing process as it is
the most effective way of determining the effectiveness of the prevention plan. If there are
persistent signs of redness over a pressure area, the prevention plan needs intensifying. The
resilience of skin in the elderly is often impaired. Any prevention plan should consider the use
of emollients if the skin is dry or barrier products if the skin is excessively moist (Bou et al,
2005; Beekman et al, 2009).
6. Pressure Ulcer Treatment
Many of the strategies used for pressure ulcer treatment are the same as those employed for
pressure ulcer prevention, although they may be more intensive than those used in
prevention. For example, a more sophisticated support surface may be required. It may be
helpful to identify the factors/events which led to the development of the pressure ulcer so
that they can be addressed where possible. It must also be accepted that for some patients,
palliative care may be more appropriate than curative treatment.
This section focuses mainly on the wound care aspect of pressure ulcer treatment.
Assessment of the pressure ulcer should include:
 Category – shows severity
 Size
 Position on the body – may affect dressing selection
 Level of exudate – will affect dressing selection and frequency of dressing change
 Pain assessment – many ulcers are painful for the patient
Having assessed the ulcer, the treatment objectives and plan of care can be determined. The
overall all goals are to achieve a healthy wound bed and promote healing, however, wound
debridement and control of exudate may be necessary in the first instance. An appropriate
wound management product should be selected meet the wound requirements. Table 1
provides information about the range of products that are widely available. Keeping a record
of simple measurements and wound appearance will provide information about the progress
of the ulcer. Pain management will ensure the patient is comfortable.
Table 1: Wound Management Products in General Use
Category
Comment
Alginates
Useful for all wounds with moderate to heavy exudate
4
Cadexomer iodine
Use for sloughy or infected wounds with heavy exudate
Capillary - action
Wicks exudate away from wound surface, only for heavily
exuding sloughy wounds
Use with care on fragile skin. Best on epithelialising wounds with
low exudate
Foams have variable levels of absorbency depending on the
brand. Best on granulating wounds
May be found as a topical or in combination with other products
e.g. alginate. For use in infected wounds
May be used for most types of wounds with low to moderate
exudate. Not suitable for infected wounds
Greater absorbent capacity than hydrocolloids. Useful for
wounds with moderate to heavy exudate
Donate moisture to dry sloughy or necrotic wounds and assist
autolytic debridement. Can be used on wounds with low
exudate. Not suitable for infected wounds
Silver is an antibacterial and is generally found as a composite
dressing with other products e.g. alginates, foams, hydrocolloids.
Use on infected wounds
These dressings are non-adherent and best used on granulating
wounds. Some incorporate a pad for greater absorbency
Films
Foams
Honey
Hydrocolloids
Hydrocolloid - fibrous
Hydrogel
Silver
Soft polymers
Healing may not be a fast process, but generally as long as the patient has adequate
pressure redistribution, good nutrition and appropriate wound management, the ulcer will heal
in most instances.
7. Models of Service Provision
In the UK most pressure ulcer services are run by Tissue Viability Nurses (TVNs). They
oversee the provision of pressure relieving equipment such as mattresses and beds as well
as working with the clinical team to plan care provision for individual patients.
8. Responsibilities / Role of the Geriatrician
Individuals between 70 and 75 years of age have double the incidence of pressure ulcers
compared with 55 to 69 year-olds. The greatest incidence of pressure ulcers occurs in the 80
to 84 year age group (Perneger et al, 1998). More than two-thirds of the elderly with pressure
ulcers are female. Geriatricians will, therefore, encounter individuals at risk of pressure
ulceration as well as those with established pressure ulceration on a regular basis. As part of
Comprehensive Geriatric Assessment and MDT working they are best placed to manage
such individuals appropriately. Additionally, familiarity with risk stratification scales and
relevant, often local, guidelines and policies will prove invaluable adjuncts to optimal
management. An excellent further summary of the whole topic is available by Grey (2006).
9. Audit (including clinical governance)
Audit of pressure ulcers takes the form of prevalence and incidence surveys. They are
generally undertaken by the TVNs and may form part of the CQUIN in some regions.
Pressure ulcers may also be the subject of root cause analysis and serious untoward
incidents reports. The new NHS Safety Thermometer will providing a constant monitoring of
the incidence of ulcers, but of course will rely on self-reporting, and the inaccuracies inherent
with multiple assessors potentially using slightly different non-standardised criteria.
5
10. Recommendations





A Comprehensive Geriatric Assessment will identify relevant patient factors in relation
to pressure ulceration which ensure an effective management plan
The majority of pressure ulcers can be prevented by the use of appropriate
prevention strategies
Patients should have a comprehensive skin assessment as well as assessment of
their risk profile before determining a prevention plan
Patients with established pressure ulcers require intensified prevention strategies and
an overall wound assessment including pain assessment.
Auditing pressure ulcer incidence is an important method of monitoring the quality of
patient care.
11. References
Beeckman D, Schoonhoven L, Verhaeghe, Heyneman A, Defloor T (2009) Prevention and
treatment of incontinence-associated dermatitis. Journal of Advanced Nursing, 65 (6) 11411154
Bou JE, Segovia GT, Verdu SJ, Nolasco BA, Rueda LJ, Perejamo M (2005) The
effectiveness of a hyperoxygenated fatty acid compound in preventing pressure ulcers.
Journal of Wound Care, 14 (3) 117-121
Cereceda FC, Gonzalez GI, Antolin JFM< Garcia FP, Tarrazo ER, Suarez CB, Alvarez HA,
Manso DR (2003) Detection of malnutrition on admission to hospital. Nutricion Hospitalaria,
18 (2) 95-100
Grey, JE, Harding KG, Enoch A. ABC of Wound healing : Pressure Ulcers
BMJ 2006;332:472-4
Guigoz Y, Lauque S, Vellas BJ (2002) Identifying the elderly at risk for malnutrition. The Mini
Nutritional Assessment. Clinics of Geriatric Medicine
Margolis D, Knauss J, Bilker W, Baumgarten M (2003) Medical conditions as risk factors for
pressure ulcers in an out-patient setting. Age & Ageing, 32: 259-264
NPUAP/EPUAP (2009) Prevention and Treatment of Pressure Ulcers: Clinical Practice
Guideline. NPUAP, Washington DC
Perneger TV, Héliot C, Raë A-C, Borst F, Gaspoz J-M (1998) Hospital-Acquired Pressure
UlcersRisk Factors and Use of Preventive Devices. Archives Internal Medicine, 158(17):19401945
Russell CA, Elia M (2008) Nutrition Screening Survey in the UK in 2007.
http://bapen.org.uk/pdfs/nsw/nsw.07_report.pdf (accessed 24.11.08)
Vanderwee K, Clark M, Dealey C et al Pressure Ulcer prevalence in Europe: a pilot study. J
Eval Clin Pract. 2006;13:227-235.
Author : Carol Dealey for BGS Policy Committee (June 2012)
6