Pressure ulcers, commonly seen in immobile individuals, are painful skin injuries caused by prolonged pressure, affecting over 2.5 million Americans annually. They can be classified into four stages based on severity, with appropriate assessment and documentation being crucial for effective treatment. Preventative measures and daily skin inspections are emphasized to minimize the risk of ulcer formation.

1. Pressure Ulcers –
Symptoms, Assessment
and Documentation
Pressure ulcers are painful and distressing. Accurate assessment and clear
documentation could make immediate care and treatment possible.
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Pressure ulcers or bed sores are damages to the skin and
underlying tissue caused by staying in one position for too long.
This condition is common among elderly people, those who use
a wheelchair or stay in bed for a long time, who cannot move
certain parts of their body without help, have a disease that
affects blood flow, including diabetes or vascular disease, have
Alzheimer’s disease or some other condition that affects their
mental state, have fragile skin, cannot control their bladder or
bowels, or do not get enough nutrition. Pressure ulcers are very
painful and can affect any area of the body; they are more
common in places where the bones are close to the skin. The
most common places are elbows, hips, heels, ankles, shoulders,
back, buttocks and back of the head.
The Agency for Healthcare Research and Quality (AHRQ)
reports that more than 2.5 million people in the United States
develop pressure ulcers every year. These ulcers can develop
very quickly, and may take less than an hour to develop in
people who are at high risk.

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What Do Pressure Ulcers Look Like?
Pressure ulcers look different, depending on how severe they
are. They can be classified into stages.
 Stage I - The affected area of the skin appears red in fair-
complexioned people, and purple or blue in people with a
darker complexion. This discolored patch does not turn white
when pressed. This is an indication that a pressure ulcer is
forming. The skin may be warm or cool, firm or soft.
 Stage II - At this stage, the skin is broken and leaves an open
wound, or looks like a pus-filled blister. The area is swollen,
warm, or red. The sore may ooze clear fluid or pus.
 Stage III - The sore looks like a crater at this stage, and may
have a bad odor. It may show signs of infection such as red
edges, pus, odor, heat, or drainage. The tissue in or around the
sore is black if it has died.
 Stage IV - At this stage, the sore is deep and big and there is
damage to muscle or bone underneath.
Other types of pressure sores that don't fit into these stages
include:

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 Unstageable - Pressure sores covered in dead skin that is
yellow, tan, green, or brown. The dead skin makes it hard to
tell how deep the sore is.
 Suspected deep tissue injury - These include sores that
develop in the tissue deep below the skin. The area may be
dark purple or maroon. There may be a blood-filled blister
under the skin.
Early–stage pressure sores often heal well with timely and
appropriate treatment. However, prevention of bedsores is easier
than treating them.
Assessment and Documentation of Pressure Ulcers
A head-to-toe inspection of the skin must be done on admission
and at least daily. Things to be assessed include color of the
skin, temperature of the skin, skin texture/ elasticity, skin
integrity, and moisture status. The assessment should focus on
high-risk areas such as bony prominences, and areas of redness.

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While documenting pressure ulcers the following details should
be included.
 Type of wound and location
 The stage, size of wound such as length, width and depth
 Any undermining/tunneling/sinus tracts
 Any exudates -- this includes type, amount, or odor
 Wound bed of various types of tissue in wound
 Edges of wound
 Surrounding tissue including color, edema, firmness
 Any warmth or pain, rashes and border shape
 Any conditions that would affect healing
Healthcare centers use wound care software programs to
accurately document wound details, thus helping healthcare
providers to obtain patient health information instantly and
securely.