Lesson 2 of 1
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Preventing Pressure Ulcers Lesson # 2

September 20, 2014

Lets start this lesson by watching Preventing and Caring for Pressure Ulcers video by Maureen MacCathy

The Problem of Pressure Ulcers
Each year, more than 2.5 million people in the United States develop pressure ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care utilization. Moreover, the Centers for Medicare & Medicaid (CMS) no longer provides additional reimbursement to hospitals to care for a patient who has acquired a pressure ulcer while under the hospital’s care. Thus, pressure ulcer prevention presents an important challenge in acute care hospitals.

Key points

  • Pressure ulcers result from long periods of uninterrupted pressure exerted on the skin, soft tissue, muscle, and bone. They occur more frequently over a bony prominence such as the sacrum, the hip, or the heel
  • Two thirds of pressure ulcers occur in patients over 70 years of age
  • Prevention is the most important factor in managing pressure ulcers
  • Presentation of skin ulcer is described by stage, from erythema (stage 1) to full thickness and involvement of underlying bone or muscle (stage 4)
  • Treatment involves repositioning/removal of pressure source and good wound care. Debridement and surgical reconstruction may be necessary for necrotic, deep, or poorly healing wounds. Treatment with appropriate antibiotics is indicated if cellulitis or osteomyelitis are present
  • Urgent medical attention is required for patients with sepsis
  • Prognosis for full healing of stage 1 and 2 pressure ulcers is good. Stage 3 and 4 pressure ulcers are much less likely to heal spontaneously even after months of treatment, and if healed they are often associated with scarring. Surgical closure may be required.


  • Pressure ulcers result from localized areas of ischemia, tissue inflammation, and tissue anoxia, and, ultimately, from cell death, necrosis, and ulceration.
  • The hip and buttock region accounts for approximately 67% of all pressure ulcers
  • The malleolar, heel, patellar, and pretibial locations of the lower extremities account for approximately 25%
  • Ulcers can also occur in the nares or in the corners of the mouth in patients with nasogastric or endotracheal tubes



Patients get a pressure ulcer for a number of reasons. Some of the reasons why people get them are below.

  • Age. The normal aging process changes the skin and the blood circulation. The old person’s skin can be dry and very fragile. It can get irritated; it can break open into a sore and can even tear very easily. Older people may also have poor circulation. Their blood, with oxygen, may be cut off or very limited. When oxygen is not fed to the skin, it is hard to keep the skin healthy and without injury.
  • Lack of mobility. Pressure ulcers occur when people are not up and walking. They form when a person stays in the bed, chair or wheelchair for a long time. Blood is cut off to areas where bones are close to the skin when a person stays in a chair or in bed for a long time. The weight of the body pushes against a bony area to cut off the blood and oxygen to that area. The sacrum, elbows, ears, shoulders, toes and heels are some of these bony areas that can break down when a person is kept in one position for a long period of time.
  • Poor diet. Patients and residents with a poor diet are at risk for pressure ulcers. The skin and other tissue, as well as the rest of the body, does not get the food and nutrition it needs to be healthy and without injury if the diet is not good. Patients who do not eat or drink do not get a good diet unless something like a tube feeding is used.
  • Moisture. Residents and patients who are wet are at risk for pressure ulcers. Patients that are incontinent of urine or stool, those that sweat a lot and those that have draining wounds are at risk for pressure ulcers. Moisture makes the skin soft. This softness leads to skin breaks.
  • Mental, neurological and other physical problems. When a patient or resident is confused, very sleepy, or in a coma, they may not turn like other alert patients normally do even when they are sleeping. People that do not have a normal sense of pain and the physical ability to turn will remain in one position for a very long time unless someone else turns them. If a patient stays in one position for a long time, they will get a pressure ulcer.
  • Friction and shearing. Friction and shearing occur when a patient or resident is pulled up in bed or in the chair. These forces can make the skin irritated. They can cause the skin to break and develop a pressure ulcer.
  • Bed sheets and chairs with wrinkled sheets or hard objects. Uneven pressure is created when sheets are wrinkled. This leads to pressure ulcers. Objects such as spoons, tissue boxes, eye glasses, food crumbs, hair pins and other hard objects that are left in the bed or sitting chair also cause pressure and pressure ulcers.
  • Pressure ulcers in the past. Patients who have had a pressure ulcer in the past are at risk of getting another one.



Pressure ulcers form and get worse unless they are prevented with very good nursing care. A warning sign of a pressure ulcer is when pink skin on a bony area turns white. This white color happens because the red colored blood to the skin area has been cut off with pressure. Skin can NOT stay pink when blood is not going to an area. Later, the skin will then become red and irritated if this pressure remains and the patient is not turned. The skin may now feel very warm and the patient may tell you that they feel burning in the area.

If the pressure ulcer process continues, the top layers of the skin will break away. It will become an open sore if the pressure is not stopped and the area is treated. It will get worse and worse until all the skin layers are broken down and the bone, muscle or joint is seen. The worst pressure ulcers are those that affect the bones themselves.

Pressure ulcers are categorized into four stages



Stage 1

Nonblanchable erythema of intact skin of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stage 2

Partial thickness skin loss involving epidermis, dermis or both. It can also be an abrasion, blister or shallow crater without slough. May also present as an intact or open/ruptured serum filled blister.

Stage 3

Full thickness skin loss. Subcutaneous fat  may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling

Stage 4

Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.


Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. When an eschar is present, accurate staging is not possible

Suspected Deep Tissue Injury (commonly known as DTI) 

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.


Most people move about in the bed while they are sleeping so they do not get a pressure ulcer. Others are NOT able to move about in their bed while they are sleeping and even when they are awake. For example, a person that is in a coma will not move about in the bed on their own. People that have had a stroke may not be able to move about in the bed on their own.


Pressure ulcers can lead to pain and even death. Pressure ulcers are difficult and very costly to cure once they have formed. It is, therefore, important that nursing assistants and other team members prevent pressure ulcers before they start. Some the things that you can do to prevent pressure ulcers are listed below.

Ways that a nursing assistant can prevent pressure ulcers:

  • Provide good skin care. Use mild soap and gentle strokes with a soft washcloth when giving a bath to a resident or patient. Rinse the skin well and then pat it dry with a soft towel. Use a bland lotion to lubricate dry skin. Lotion helps to keep the skin healthy and soft. No NOT use alcohol or alcohol base lotions on skin. Alcohol dries the skin. Look at areas where skin touches skin, such as under the breasts. If these areas are moist, place a light dusting of corn starch to help keep this area dry.
  • Keep the skin clean and dry. Immediately remove all wet or dirty linens, briefs and clothing. Do not let the patient remain wet or dirty with urine, feces or other fluids, including water or tea. Wash, rinse and dry all wet and dirty skin as your read above.
  • Turn and position patients at least every 2 hours. Patients and residents who stay in bed, the chair or wheelchair must be moved and re-positioned at least every 2 hours. Many patients have to be turned and positioned even more often if they are at risk for pressure ulcers. Make the time to move your patients. It takes much more time to treat a pressure ulcer than it takes to turn a patient.
  • Use a turning sheet to keep track of your positioning. Record the time that you turned and positioned your patient. Also, record the position that was used. For example, if you turn and position your patient at 10 am into the prone position, record that so you can rotate the positions as much as you can.
  • Observe and report the condition of the skin. Look at and observe the patient’s skin for signs of whiteness (blanching), redness, heat, tearing or breaks.
  • Encourage mobility. Encourage your patients to ambulate and move if it okay with their doctor. Walking and moving about increases blood flow and it keeps patients out of bed and the chair when they are able to do so.
  • Provide for toileting needs. Anticipate the patient’s need to use the commode or bathroom. Follow the patient’s bowel and bladder training program if it is ordered. Patients that are wet with urine or soiled with feces are at risk of getting a pressure ulcer.
  • Encourage and provide nutrition and fluids. Encourage the resident or patient to eat good foods and lots of fluids. Every time you are with a patient, ask them if they would like a drink of water or juice. Make meal times happy and pleasant. Encourage the patient to eat their whole meal. If they are not eating, offer them another choice of food. Report and record all food and fluid intake.
  • Use pressure reducing cushions, mattresses, beds, booties, elbow pads, etc. These items lower pressure when patients stay in the bed or chair for long periods of time.
  • Do NOT elevate the head of the bed more than 30 degrees, unless ordered. If the bed is higher than this, it will cause friction, shearing and the need to pull the patient up in the bed more often than necessary.
  • Do NOT use any donut type devices. These devices create uneven pressure, a force that leads to pressure ulcers.
  • Do NOT allow a patient to remain on a bedpan for a long period of time. Remaining on a bedpan also creates pressure, a force that leads to pressure ulcers.
  • Use a lifting device like a Hoyer Lift or a lifting sheet to move or lift a patient. Do NOT drag a person’s body along bed sheets. Lifting devices and lifting sheets lower friction and shear. They also prevent patient and staff injury.
  • Document and report all your patient observations and care. Nursing assistants must report if the patient is not eating or drinking, if they are not getting out of bed and if you see a red area on the patient’s skin.

The roles of other healthcare providers in the prevention of pressure ulcers:

  • Nurses. Nurses and some other members of the healthcare team assess patients for their risk of developing pressure sores. They also plan care and provide care that prevents and treats pressure sores.
  • Dietitian. The dietitian assesses the patient’s nutrition status. They plan nutritional care with the doctor and other members of the health care team. Some patients may need supplements, like Ensure.
  • Infection control nurse and the skin care team. These health care team members monitor and coordinate the care of a patient with a pressure ulcer in some hospitals and nursing homes.


Most pressure ulcers can be predicted and prevented. Nursing assistants play a very important role in their prevention. If a patient is at risk for getting a pressure ulcer, all preventive measures, as stated by your facility, must be done and documented. Preventing and treating pressure ulcers needs the entire team to work together!



Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.

Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.