This document provides an overview of pressure sores including their definition, epidemiology, pathogenesis, risk factors, staging classifications, prevention, and management. Pressure sores, also known as bedsores or decubitus ulcers, are localized skin or tissue injuries caused by unrelieved pressure. They are common in hospital and nursing home patients and costly to healthcare systems. The document outlines the traditional theories behind their pathogenesis as well as intrinsic and extrinsic risk factors. Staging classifications from the National Pressure Ulcer Advisory Panel are presented along with the Braden and PUSH risk assessment tools. Prevention strategies aim to reduce pressure, shearing forces, and moisture on the skin. Management is based on the stage and may involve wound cleaning, dress

1. Pressure Sores
Andre Sookdar
Class of 2013

2. Objectives
• Definition
• Epidemiology
• Pathogenesis
• Risk Factors
• Stage & Risk Assessment
• Prevention
• Management

3. Definition
• A Pressure sore is a localized injury to
the skin or underlying tissue as a result
of unrelieved pressure.
• Decubitus Ulcer, bedsore

4. Epidemiology
• Between 1-3 million US affected
• 11 - 18% nursing home residents (2004)
• 9 - 60% hospital
• 3 - 18% home
• Health care expenditure $5 Billion US/year
• 1.4 – 2.1 Billion pounds (UK)/year
• More than 17,000 lawsuits annually
• The longer the patient stays in a hospital
or nursing home the greater the risk

5. Pathogenesis
Traditional Theory
• Prolonged Pressure
• Friction
• Shearing Forces
• Moisture

6. Pathogenesis
• Pressure: When external pressures are
greater than capillary pressure (12-
32mmHg) ischaemia results
• Intermittent pressure relief helps prevent
ulcer formation
• Friction: Compromise of the protective
stratum corneum decreases the pressure
required for ischaemia
• The loss of the skin’s ability to act as a
barrier further enhances ulcer formation

7. Pathogenesis
• Shearing Forces: When the patient is
raised at an angle > 30˚, shearing
forces occur between the deep fascia
and the outer skin
• Moisture: Chronic moist environment
(incontinence, perspiration) leads to
tissue damage and ulcer formation

8. Pathogenesis

9. Pathogenesis
• Impairment in lymphathic flow 
increase in metabolic waste products
• Reperfusion injury
• Deformation of tissue cells

10. Common Sites
• Commonly occurs at bony
prominences, e.g. sacrum, greater
trochanters, heels, ischial tuberosities
• 95% occur on the caudal aspect of the
body; 65% in the pelvic area, 30% on
the lower limbs

12. Intrinsic Risk Factors
Limited Mobility
• Spinal cord injury
• CVA
• Parkinson Disease
• Alzheimer Disease
• Pain
• Fractures
• Postsurgical
• Coma or sedation
• Arthropathy

13. Intrinsic Risk Factors
Poor Nutrition
• Anorexia
• Dehydration
• Poor dentition
• Poverty or lack of access to food
• Dietary Restriction

14. Intrinsic Risk Factors
Co-morbidities
• Diabetes
• Depression
• Peripheral Vascular
Disease
• Decreased pain
sensation
• Immunodeficiency
• Corticosteroid
effects
• Congestive heart
failure
• Malignancies
• Renal Disease
• COPD
• Dementia

15. Intrinsic Risk Factors
Aging skin
• Loss of elasticity
• Decreased cutaneous blood flow
• Changes in dermal pH
• Flattening of rete ridges
• Loss of subcutaneous fat
• Decreased dermal-epidermal blood
flow

16. Extrinsic Risk Factors
• Pressure from external surface e.g.
bed, chair
• Friction from being unable to move well
• Shear forces form involuntary
movement
• Moisture – bowel or bladder
incontinence, perspiration, wound
drainage

17. National Pressure Ulcer Advisory Panel
Pressure Ulcer Staging Classification
• Stage 1 – Intact skin with non-blanchable
redness of a localized area, usually over a
bony prominence. The area may be painful,
firm, soft, warmer or cooler than adjacent
tissue.

18. National Pressure Ulcer Advisory Panel
Pressure Ulcer Staging Classification
• Stage 2 – Partial thickness skin loss,
presenting as a shallow open ulcer with a
red-pink wound bed without slough. May also
present as an intact or open serum-filled
blister. Includes tears, tape burns,
maceration or excoriation

19. National Pressure Ulcer Advisory Panel
Pressure Ulcer Staging Classification
• Stage 3 – Full thickness skin loss. Fat may
be visible but bone, tendon or muscle tissue
are not. Slough may be present.

20. National Pressure Ulcer Advisory Panel
Pressure Ulcer Staging Classification
• Stage 4 – Full-thickness tissue loss with
exposed bone, tendon or muscle. Slough or
eschar may be present.

21. National Pressure Ulcer Advisory Panel
Pressure Ulcer Staging Classification
• Unstageable – Full thickness tissue loss in
which the base of the ulcer is covered by
slough or eschar. Until enough of the base is
exposed, the true depth and stage cannot be
determined.

22. National Pressure Ulcer Advisory Panel
Pressure Ulcer Staging Classification
• Suspected Deep Tissue Injury – Purple
or maroon discoloured intact skin or blood-
filled blister due to damaged underlying soft
tissue from pressure or shearing forces. The
area may be painful, firm, mushy, boggy,
wormer or cooler than surrounding tissue

23. Risk Assessment and Evaluation
• Braden Scale
• Push Tool

24. Braden Scale
• Sensory Perception 1-4
• Moisture 1-4
• Physical Activity 1-4
• Mobility 1-4
• Nutrition 1-4
• Friction & Shear 1-3
• Score 18+ Low risk
• 15-18 Mild risk, 13-14 Moderate risk, 10-
12 High risk, below 10 Very High Risk

26. PUSH Tool

27. Prevention
Aims
• Reduce Pressure and Shearing effects
• Reduce Moisture
• General Skin Care
• Nutrition
• Co-morbidities
• Involve patient, family, caregivers

28. Prevention
• Daily skin inspection
• Bathing and skin cleaning frequency
• Moisturize skin; avoid hot water or harsh
solutions
• Assess and treat incontinence; use topical
barriers or absorbent padding when needed
• Proper re-positioning frequently; q2hrly for
those bed-bound, q1hrly for those in
wheelchairs; self re-positioning every 15
minutes for those in wheelchairs
• Avoid manipulating bony prominences

29. Prevention
• Practice proper positioning, transferring and
turning techniques to avoid friction and shearing
forces; lift don’t shift
• Use dry lubricants (cornstarch) or protective
coverings to reduce friction injury
• Institute a rehabilitation program to maintain or
improve mobility/activity status
• Consider nutritional supplementation/support for
nutritionally compromised persons

30. Prevention
• Use adjunct devices (air mattresses, limb
padding) where necessary
• Use pillows or padding to avoid bony
prominences such as knees from having
direct contact
• Elevate the head of the bed no more than
30˚ unless absolutely necessary
• Monitor and document interventions and
outcomes
• Have a fixed repositioning schedule

33. How might the Leg Ulcer and
Thumb Bruises be related?

34. Management
• Based on Staging and Investigation
• Wound swabs and cultures usually
show mixed growth
• Blood – CBC, CRP, ESR, Serum
Protein/Albumin
• MRI
• X-Rays
• Ultrasound
• Tissue Biopsy – suspect malignancy

35. Management - AAFP

36. Dressings
Dressing Type Description Indication Brand Names
Transparent Film Adhesive, semi-
permeable, allows
vaporization
Stage I and II with
light or no
exudates
Opsite, Tegaderm
Hydrogel Water/Glycerin
based gels on
gauze or dressings
Stage II, III, IV;
deep ulcers;
necrosis & slough
Acryderm, Flexigel,
Intrasite
Alginate From Seaweed Stage III, IV with
moderate to heavy
exudate
Algicell, Algisite,
Tegagen
Foam Moist, thermal
Insulation
Stage II to IV with
varying drainage
Hydrocell,
Polyderm
Hydrocolloid Occlusive or
semiocclusive;
gelatin and pectin
Stage II to IV with
sough and necrosis
Dermafilm,
Tegaderm
Moistened Gauze Gauze in saline Stage III to IV

37. Management
• Clean, barrier
• Antibiotic where appropriate
• Debride necrotic tissue

38. Complications
• Sepsis, cellulitis, endocarditis, meningitis
• Fistula formation
• Osteomyelitis, septic arthritis
• Sinus tracts
• Squamous Cell Carcinoma (Marjolin’s
ulcer)
• Amyloidosis
• Drug resistant bacteria
• Maggot infestation

39. Conclusion
• Risk
• Prevention
• Identify early
• Manage

40. The End
Thank You

41. References
• www.aafp.org
• Sussman C, Bates-jensen B. Wound Care:
A Collaborative Practice Manual for Health
Professionals 4th Ed Lippincott Williams &
Wilkins 2012
• Falabella A, Kirsner R.S. Wound Healing
Taylor & Francis Group 2005
• Ruiz J.G. Pressure Ulcers University of
Miami Grand Rounds Presentation