Synonyms: pressure ulcers, bed sores, decubitus ulcers

Pressure sores may present as persistently red, blistered, broken or necrotic skin and may extend to underlying structures, e.g. muscle and bone. A pressure ulcer may be caused by pressure, shear, friction or a combination of these. Pressure sores can develop very quickly and therefore the National Institute for Health and Clinical Excellence (NICE) recommends that patients should receive an initial (within the first 6 hours of inpatient care) and ongoing risk assessment.¹

Risk factors

• Increasing age, severely ill.
• Cardiovascular disease.
• Neurologically compromised, e.g. those individuals with spinal cord injuries, stroke or receiving epidural analgesia.
• Impaired mobility, especially wheelchair users. Pain can cause a reluctance to move and increase the risk of the development of a pressure ulcer.²
• Urinary incontinence or faecal incontinence can increase the risk of pressure ulcer development.
• Poor nutrition, obesity.
• Poor posture or use of equipment, such as seating or beds, which does not provide appropriate pressure relief.
• Cleansing with soap and water can contribute to the development of pressure ulcers.²
• Features of skin that may indicate an increased risk of a pressure ulcer include darkly pigmented skin, other discolouration of the skin, warmth, oedema, induration and hardness.²

Risk assessment¹

• Risk assessment tools should only be used as an aide-mémoire and should not replace clinical judgment.³
• Commonly used assessment scales include the Norton, Braden, and Waterlow scales.⁴ The Braden Risk Assessment Scale is considered by many to be the most valid and reliable scoring system for a wide age range of patients.⁵
• The Braden Risk Assessment Scale is a scale made up of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction and shear. Each item is scored between 1 and 4. The lower the score, the greater the risk.⁶

Assessment

Pressure ulcers can develop in any area of the body. In adults, damage usually occurs over bony prominences, such as the sacrum. Patients with pressure ulcers should receive an initial and ongoing assessment which should include:

• Health status: illness, nutrition, pain, continence, neurological (sensory impairment, level of consciousness, cognitive status), blood supply, mobility, posture, signs of local or systemic infection, medication (pressure ulcers and the person's general physical condition are very closely related and the two should be assessed together).²
• Previous pressure damage.
• Psychological and social factors.
• Ulcer assessment: should be supported by photography (calibrated with a ruler) and tracings. Ulcer assessment should include:
  • Cause of ulcer.
  • Site/location.
  • Dimensions of ulcer.
  • Stage or grade (see 'Classification system', below).
  • Exudate amount and type.
  • Local signs of infection.
  • Pain.
  • Wound appearance.
  • Surrounding skin.
  • Undermining/tracking (sinus or fistula).
  • Odour.

Reassessment of the ulcer should be performed at least weekly but may be required more frequently.

Management¹

Patients with extensive superficial pressure ulcers, Grade 3 or 4 pressure ulcers or those that are deteriorating should be referred to a specialist service.²

• Repositioning of the patient.
• Treatment of concurrent conditions which may delay healing.
• Pressure relieving support surfaces such as beds, mattresses, overlays or cushions.
• Local wound management using modern or advanced wound dressings and other technologies.
• Patients with identified Grade I pressure ulcers are at a significant risk of developing more severe ulcers and should receive interventions to prevent deterioration.
• Pain relief:
  • Pain is often significant and disabling for those with pressure ulcers.
  • Paracetamol may be sufficient, but patients often require stronger analgesia.
  • Non-steroidal anti-inflammatory drugs may increase peripheral oedema and are inappropriate for patients with pressure ulcers.
  • Patients may require referral to a pain clinic.
• Infection control:
  • All pressure ulcers are colonised with bacteria. Most local infection can be managed using antimicrobial wound products and systemic antibiotics should not be used routinely for local infection.²
  • Reduce risk of infection and enhance wound healing by hand washing, wound cleansing and debridement. Protect from exogenous sources of contamination, e.g. faeces.⁸
  • If purulent material or foul odour is present, more frequent cleansing and possibly debridement are required.
  • When there are clinical signs of infection which do not respond to treatment, radiological examination should be undertaken to exclude osteomyelitis and joint infection.⁸
  • Systemic antibiotics are required for patients with bacteraemia, sepsis, advancing cellulitis or osteomyelitis.⁸
  • Reduce the risk of environmental contamination from infected pressure ulcers, including the use of personal protective equipment, hand hygiene, and cleaning and decontaminating equipment after use.²
• Nutritional support should be given to patients who have an identified nutritional deficiency.
• Adjunct therapies Include electrotherapy and low laser irradiation. There is currently insufficient research to recommend their general use.⁸

Mobility and positioning

Patients at risk of pressure ulcer development should be positioned to minimise pressure, friction and shear, and the potential for further tissue damage. Patients who can move independently should be encouraged and enabled to do so.²

• All patients with pressure ulcers should actively mobilise, change their position or be repositioned frequently.
• Passive movements should be considered for patients with pressure ulcers who have compromised mobility.
• Avoid positioning individuals directly on pressure ulcers or bony prominences.

Pressure relief

• Pressure relieving equipment, e.g. alternating pressure systems, redistributes the load or relieves the pressure at regular intervals. Pressure reducing equipment redistributes pressure by spreading the weight over a larger surface area, e.g. mattresses, cushions and dynamic air loss systems.
• Patients with pressure ulcers should have access to appropriate pressure relieving support surfaces 24 hours a day and this applies to all support surfaces.¹
• Current consensus recommends that:¹
  • All individuals assessed as having a Grade 1-2 pressure ulcer should be placed on a high specification foam mattress or cushion with pressure-reducing properties combined with close observation of skin changes and a documented positioning and repositioning regime.
  • If there is any perceived or actual deterioration of affected areas or further pressure ulcer development an alternating pressure mattress (replacement or overlay) or sophisticated continuous low pressure system (e.g. low air loss, air fluidised, air floatation, viscous fluid) should be used.
  • Depending on the location of an ulcer, individuals assessed as having Grade 3-4 pressure ulcer (including intact eschar where depth cannot be assessed) should be placed on an alternating pressure mattress or sophisticated continuous low pressure system.
  • If alternating pressure equipment is required, the first choice should usually be an overlay system.

Dressings and topical agents

• There is no conclusive research evidence to guide clinicians' decision-making about which dressings are most effective in pressure ulcer management.
• Wounds should be cleansed with warm tap water or warm saline to remove visible debris. Irrigation of the wound or showering is recommended. Excess loose slough and exudate should be removed prior to a dressing change.
• However, professional consensus recommends that modern dressings (e.g. hydrocolloids, hydrogels, foams, films, alginates, soft silicones) should be used in preference to basic dressing types, e.g. gauze, paraffin gauze and simple dressing pads.¹
• Barrier creams should not be used with superficial pressure ulcers.

Debridement²

Debridement may be autolytic (see below), enzymatic (using enzymes to produce slough of necrotic tissue), mechanical (allowing a dressing to become moist and then wet before manually removing the dressing), or surgical.

• The presence of devitalised tissue delays the healing process.
• Superficial pressure ulcers may benefit from autolytic debridement techniques, which use the body's own enzymes and moisture to rehydrate, soften and liquefy hard eschar and slough.
• Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue.
• For individuals who are terminally ill or with other comorbidities, overall quality of life should be considered before deciding whether and how to debride.

Prognosis

• Pressure ulcers are often slow to heal, because of continued adverse factors such as pressure or poor nutrition.
• May spread to deep tissues and also cause localised infection, including osteomyelitis, and systemic infection.
• The presence of pressure sores is associated with a twofold to fourfold increased risk of death, but this is because pressure sores are a marker for underlying disease severity and other comorbidities.⁹

Prevention¹⁰

• Skin injury due to friction and shear forces should be minimised through correct positioning, transferring and repositioning techniques.
• Eliminate any source of excess moisture due to incontinence, perspiration or wound drainage.
• Reduce underlying risk factors such as poor nutrition.
• Education and training, e.g. mobility, positioning, skin care, use of equipment, for patients and their carers.

Document references

1. Pressure ulcers: The management of pressure ulcers in primary and secondary care, NICE Clinical Guideline (2005)
2. Best Practice Statement: prevention and management of pressure ulcers, NHS Quality Improvement Scotland (March 2009); [pdf]
3. Pressure relieving devices, NICE Clinical Guidance (2003)
4. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, et al; Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. 2006 Apr;54(1):94-110. [abstract]
5. Pressure Ulcer Treatment Guidelines, European Pressure Ulcer Advisory Panel, 2003
6. Braden Risk Assessment Tool, NHS Quality Improvement Scotland; [pdf]
7. Pressure Ulcer Grading System, European Pressure Ulcer Advisory Panel, 2003
8. Bergstrom N, Braden B, Kemp M, et al; Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nurs Res. 1998 Sep-Oct;47(5):261-9. [abstract]
9. Thomas DR, Goode PS, Tarquine PH, et al; Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc. 1996 Dec;44(12):1435-40. [abstract]
10. Pressure Ulcer Prevention Guidelines, European Pressure Ulcer Advisory Panel, 2003

Internet and further reading

• European Pressure Ulcer Advisory Panel; Home page

Acknowledgements