Pressure Ulcers Prevention & treatment

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Pressure sores (decubitus ulcers)

A pressure sore refers to skin or tissue damage that occurs when there is decrease blood circulation due to pressure in a specific area.

Initially, slight redness on the affected area can be noticed (the first sign of tissue damage). The tissue underneath perishes due to poor blood supply. Various skin layers, muscles and bones can be affected. Areas that are particularly at risk are the sacrum, heels, elbows and shoulder blades.

Pressure sores can be mostly avoided through preventive measures such as formal risk assesment and specific risk mitigation (pressure relief, preventive skin care) by minimizing risk factors.

Once a pressure sore has developed, it is important to draw up a coordinated treatment plan to induce healing and eliminate all the disruptive factors. The basic prerequisites for wound healing must be met. These include a clean wound, functioning circulation and adequate nutrition in terms of both calories and nutrients, along with adequate fluid intake. The latter is often a problem in elderly people (as a a basic rule, daily fluid intake should be 40 ml per kg of body weight).

Depending on the extent of tissue damage, pressure ulcers are categorized into four stages:

Stage 1 
The skin is not broken, but the redness does not turn white when touched.

Stage 2
Damage involves the epidermis, dermis, or both. Clinically, the damage appears as an abrasion or blister. The surrounding skin may be reddened.

Stage 3
Damage extends through all the superficial layers of the skin, fat tissue, right to and including the muscle. The ulcer appears as a deep crater.

Stage 4
Damage includes destruction of all soft tissue structures and bone or joint structures.

Anyone can develop a pressure sore, but elderly, bed-ridden, paralyzed and malnourished patients are at higher risk.

Identifying individuals at risk of pressure ulcers and initiating preventive measures are vital steps in reducing pressure ulcer incidents. The individual risk of developing a pressure ulcer can be determined by using risk assessment tools such as the Braden Scale.

The Braden Scale is a rating scale made up of 6 sub-scales that asses:

  • Sensory / perception (ability to respond meaningfully to pressurerelated discomfort) 
  • Moisture (degree to which the skin is exposed to moisture)
  • Activity (degree of physical activity)
  • Mobility (ability to change and control body position)
  • Nutrition (usual food intake pattern)
  • Friction and shear

The most important aspect in prevention and treatment of pressure sores is certainly pressure relief. This can be best achieved by frequent patient repositioning and mobilization, but also using adequate mattresses or specific pressure-reducing  equipment. Appropriate treatment should include thorough wound cleansing, avital tissue removal and a wound environment free of urine and feces. Stage 3 and 4 ulcers often require surgical debridement.

Pressure Ulcer Prevention & Management

Classification of ulcers based on EPUAP/NPUAP, 20111

Classification of ulcer: 1

  • Non-blanchable redness of intact skin usually over a bony prominence.
  • Discoloration of the skin, warmth, edema, hardness or pain compared to adjacent tissues may also be present.
Treatment goals: 
  • Skin repair
    Restore capillary function
Local wound treatment:
  • Promote skin integrity by using hyper-oxgenated fatty acid-based products (e.g. Linovera®1)
  • Prevent skin breakdown due to friction or shear using skin barrier products

Classification of ulcer:
2 - Non-infected 

  • Partial thickness skin damage (blister)
  • Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates deep tissue injury) 
  • Check for skin maceration
Treatment goals: 
  • Provide a clean wound bed for granulation tissue
Local wound treatment:

Classification of ulcer:
3 - Non-infected 

  • Full-thickness tissue 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.
Treatment goals: 
  • Remove slough
  • Provide a clean wound bed for granulation tissue
Local wound treatment:

Classification of ulcer:
4 - Non-infected 

  • Full-thickness tissue loss with bone, tendon or muscle visible.
  • Slough or eschar may be present. Often includes undermining and tunneling.
Treatment goals: 
  • Remove slough
  • Provide a clean wound bed for granulation tissues
Local wound treatment:

Classification of ulcer:
2 - 4 - Infected 

  • Signs and symptoms of infection, such as discoloration, swelling, heat and odor
Treatment goals: 
  • Reduce bacterial load
  • Manage exudate/odor
  • Prevent/remove biofilm
  • Provide a clean wound bed for granulation tissue
Local wound treatment:


1. Recommended use as per guidelines EPUAP, 2012 see:

2. NOTE: As Stage IV PUs may involve exposed cartilage, special caution is required. Some products (e.g. Prontosan®) are contraindicated for the use on hyaline cartilage. In all cases, a careful risk-benefit assessment should be

performed. Decisions on product use must lie with the attending physician and normal saline used instead of Prontosan® where indicated.

3. Use as secondary dressing an appropriate absorbent/low adherent moist dressing in flat or anatomical shape (e.g. Askina® Foam/Askina® Heel/Askina®/Askina® DresSil Heel/Askina® DresSil Sacrum)

Related documents:

Description Document Link
Quick guide Pressure Ulcers.pdf
pdf (963.6 KB)