Keri Holmes-Maybank, MD
Medical University of South Carolina
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2.5 million hospitalized patients/yr
60,000 die/yr from pressure ulcer
complications
◦ 1 in 25 if pressure ulcer reason for admit
◦ 1 in 8 if pressure ulcer secondary diagnosis
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10-18% acute care patients
0.4-38% acute care new ulcers
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80% increase pressure ulcer related
hospitalizations 1993-2006
Length of Stay 13-14 days (average LOS 5
days)
$9.2-15.6 billion in 2008
1999-2002 awards avg $13.5 million
$312 million in one case
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Reduces quality of life
Interfere with basic activities of daily living
Increased pain
Decrease functional ability
Infection – OM and septicemia
Increase length of stay
Premature mortality
Deformity
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Localized injury to the skin and/or underlying
tissue
0ver a bony prominence
Result of pressure, or pressure in
combination with shear.
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Pressure is the force that is applied
perpendicular to the surface of the skin.
Compresses underlying tissue and small
blood vessels hindering blood flow and
nutrient supply.
Tissues become ischemic and are damaged or
die.
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Shear occurs when one layer of tissue slides
horizontally over another, deforming adipose
and muscle tissue, and disrupting blood flow.
Ex: when the head of the bed is raised > 30
degrees.
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Occiput
Ear
Scapula
Spinous Process
Shoulder
Elbow
Iliac Crest
Sacrum/Coccyx
Ischial Tuberosity
Trochanter
Knee
Malleolus
Heel
Toe
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Any skin surface subjected to excess pressure
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Oxygen tubing
Drainage tubing
Casts
Cervical collars
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Bed bound individuals form a pressure ulcer
in as little as 1-2 hours.
Those in chairs may form a pressure ulcer in
even less times because of greater relative
force on skin.
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Expert panels recommend use of risk
assessment tools.
Tool is better than clinical judgment alone.
Scores are predictive of pressure ulcer
formation.
Patients with a risk assessment have better
documentation and more likely to have
prevention initiated.
Braden Scale
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Limited ability to reposition self in bed or
chair
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Stroke with residual deficits
Post-surgical
Paraplegic
Quadraplegic
Wheelchair bound
Bed bound
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Sensory perception
Moisture
Activity - degree of physical activity
Mobility – ability to change body position
Nutrition
Friction and Shear
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Ability to respond meaningfully to pressurerelated discomfort.
Completely Limited
◦ No moan/flinch, cannot feel pain most of body
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Very Limited –
◦ Responds only to pain, cannot feel pain ½ body
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Slightly Limited –
◦ Responds to command, cannot feel pain 1-2 limbs
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No Impairment
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Degree to which skin is exposed to moisture.
Constantly Moist
Very Moist
◦ Often but not always, change sheets each shift
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Occasionally Moist
◦ Extra linen change a day
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Rarely Moist
◦ Only routine linen change
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Degree of physical activity.
Bedfast
Chairfast
◦ Assisted into chair, cannot or barely walk
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Walks Occasionally
◦ Very short distance, most shift in bed
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Walks Frequently
◦ Walks outside room or in room
every 2 hours
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Ability to change and control body position.
Completely Immobile
Very Limited
◦ Unable to make frequent or significant changes
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Slightly Limited
◦ Makes frequent but small changes
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No Limitation
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Usual food intake pattern.
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Very Poor
◦ 1/3 meal, <2 servings protein, NPO w IVF
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Probably Inadequate
◦ ½ meal, 3 servings protein, poor tube feeds
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Adequate
◦ >1/2 meals, 4 servings protein, supps, TF or TPN
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Excellent
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Sliding, rubbing against sheets, bed, chair, etc.
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Problem
◦ Mod-max assist, slides, cannot move without slide
against sheets, spasticity, contractures, agitation
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Potential Problem
◦ Feeble, min assist, occ slides, indep moves with slide
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No Apparent Problem
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Braden Scale score of 18 or less initiate
prevention.
Score of 1 or 2 initiate specialty bed.
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Partial thickness wound involves ONLY the
epidermis and dermis – Stage II.
Full thickness wound involves the epidermis
and dermis and extends into deeper tissues
(subcutaneous fat, muscle) – Stages III and IV.
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The ulcer appears as a defined area of
redness that does not blanch (become pale)
under applied light pressure – Stage I.
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Tissue destruction underneath intact skin at
the wound edge.
Wound edges are not attached to the wound
base.
Edges overhang the periphery of the wound.
Pressure ulcer may be larger in area under
the skin surface.
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Tunnel is a narrow channel of tissue loss that
can extend in any direction away from the
wound through soft tissue and muscle.
Tunnel may result in dead space which can
complicate wound healing.
Depth of the tunnel can be measured using a
cotton-tipped applicator or gloved finger.
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INTACT SKIN.
NON-BLANCHABLE redness of a localized
area.
Difficult to detect in individuals with dark
skin tones - affected site is deeper in color.
Surrounding skin will feel different than
effected area.
May indicate “at risk” persons.
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Partial thickness loss of dermis presenting as
shallow open ulcer with a RED-PINK wound
bed.
Shiny or dry shallow ulcer.
No slough or bruising.
BLISTER - intact, open or ruptured serum or
serosangineous-filled.
Tissue surrounding the areas of epidermal
loss are erythemic.
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FULL-THICKNESS tissue loss.
Subcutaneous fat may be visible.
Bone, tendon, or muscle is NOT visible or
directly palpable.
Slough may be present but does NOT obscure
the depth of tissue loss.
May include undermining and tunneling.
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The depth of a Stage III pressure ulcer varies
by anatomical location.
The bridge of the nose, ear, occiput and
malleolus do not have subcutaneous tissue so
Stage III ulcers can be shallow.
Areas of significant adiposity can develop
extremely deep Stage III pressure ulcers.
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FULL-THICKNESS tissue loss.
BONE, TENDON, or MUSCLE is visible or
directly palpable.
Slough or eschar may be present but does
NOT obscure wound bed.
Often includes undermining and tunneling.
Can extend into supporting structures (fascia,
tendon or joint capsule) making osteomyelitis
or osteitis likely .
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The depth of a 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.
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FULL-THICKNESS tissue loss in which SLOUGH
(yellow, tan, gray, green, or brown), ESCHAR
(tan, brown, or black), or both COVER the
base of the ulcer.
Cannot determine true depth of wound
secondary to slough and/or eschar.
Will be either a Stage III or IV.
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INTACT SKIN.
PURPLE or MAROON.
BLOOD FILLED BLISTER.
May be difficult to detect in individuals with
dark skin tones.
Color and mechanical stiffness of the skin
(firm, mushy, boggy) assist in differentiating
between DTI and a Stage I pressure ulcer.
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Most common:
◦ Sacrum, buttocks and heels.
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Heel may look like a bruise or a blood blister.
1% resolve spontaneously.
Evolution:
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Thin blister over a dark wound bed.
Covered by thin eschar.
May rapidly evolve.
Likely become a Stage III or IV.
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Skin Tears
Venous Ulcers
Arterial Ulcers
Diabetic Ulcers
Perineal (Incontinence Associated) Dermatitis
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Separation of epidermis from the dermis or
epidermis and dermis from underlying tissue.
Thin skin, less elastic, purpura or ecchymosis.
Epidermal flap.
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Impaired arterial flow to the lower leg and foot.
Tissue ischemia, necrosis and loss
WELL DEFINED MARGINS
Toes, foot, malleolus
Thin, shiny skin, cool skin temperature,
decreased or absent hair
Painful - increase with elevation
Decreased pulse
Minimal exudate
Pale wound bed; necrotic tissue
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Decrease in blood return from leg and foot.
Between the knee and the ankle.
Thickened, brown discolored skin is noted
around the lower calf, ankle and proximal
foot.
Skin proximal and distal to the
wound is reddened.
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Ulcer that occurs in diabetics
Metatarsal head, top of toes, and foot
Neuropathy, poor microvascular circulation
Repetitive trauma, unperceived pressure, or
friction/shear
Regular wound margins
Callus around wound
Dry, cracked, warm
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Skin irritation from incontinence.
Erosion of epidermis and dermis from
mechanical injury to macerated skin.
Buttocks, perineum, and upper thighs.
Secondary infection.
Diffuse erythema.
Scaling, papule and
vesicle formation .
Tissue “weeping”.
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National Pressure Ulcer Advisory Panel and European
Pressure Ulcer Advisory Panel. (2009). Prevention and
treatment of pressure ulcers: Clinical practice
guideline. Washington DC: National Pressure Ulcer
Advisory Panel. http://www.npuap.org
https://www.nursingquality.org
Panel for the Prediction and Prevention of Pressure
Ulcers in Adults. Prediction and Prevention. Rockville
MD. Agency for Health Care Policy and Research.
1992. May. AHCPR Clinical Practice Guidelines, No. 3.
Bates-Jensen BM, MacLean CH. Quality Indicators for
the Care of Pressure Ulcers in Vulnerable Elders. JAGS
55:S409-S416, 2007.