Pressure injuries, also known as pressure ulcers, decubitus ulcers, or bedsores, are localized damage to the skin and underlying tissue caused by prolonged pressure, shear, or friction. They are a common yet preventable condition in bedridden or immobile patients, often leading to severe complications if untreated.
This article provides a comprehensive guide on pressure injuries, including what they are, their stages, risk factors, prevention strategies, and assessment tools like the Braden Scale.
What is a Pressure Ulcer?
A pressure ulcer is the breakdown of skin integrity due to unrelieved pressure, typically over bony prominences such as the sacrum, heels, hips, and elbows.
Key Features:
- Results from prolonged compression of blood vessels → reduced blood flow → tissue ischemia and necrosis
- Can range from mild redness to full-thickness tissue loss exposing muscle and bone
- Common in individuals with limited mobility, poor nutrition, or chronic illness
.jpg "Pressure Injuries (Ulcers) - Stages, Risk Factors, and Prevention")
Stages of Pressure Injuries
Type 1 (Stage 1)
- Skin intact (unbroken)
- Non-blanchable redness (does not turn white when pressed)
- Swollen tissue, possible warmth
- In darker skin, may appear blue/purple instead of red
Type 2 (Stage 2)
- Partial thickness skin loss
- Involves epidermis and dermis only
- No fatty tissue visible
- May appear as a superficial ulcer, abrasion, or blister
Type 3 (Stage 3)
- Full-thickness skin loss
- Damage to or necrosis of subcutaneous tissue
- No exposed muscle or bone
- Ulcer may extend to underlying fascia, but not through it
- May present as a deep crater, with or without tunneling
Type 4 (Stage 4)
- Full-thickness tissue loss
- Extensive destruction, with damage to muscle, bone, or supporting structures
- Deep pockets of infection and tunneling may be present
Unstageable
- Depth of the wound cannot be determined
- Covered by eschar (dead tissue) or slough (yellowish debris), hiding true severity
Risk Factors for Pressure Ulcers
A helpful mnemonic is “AVOIDS PRESS”:
- Aging skin
- Vascular disorders
- Obesity
- Immobility & incontinence
- Diabetes
- Skin friction
- Poor nutrition
- Reduced RBCs (anemia)
- Edema
- Sensory deficits
- Sedation
Clinical Note: The more risk factors present, the higher the likelihood of developing ulcers.
Prevention of Pressure Injuries
Prevention is far more effective than treatment. Key strategies include:
1. Relieve Pressure
- Use pressure-relieving devices (specialty beds, overlays, air cushions, foam-padded seat cushions).
- Avoid donut-shaped devices or synthetic sheepskins (they can worsen pressure).
2. Proper Nutrition
- Adequate protein intake to promote healing.
- Maintain hydration.
- Provide enteral nutrition if oral intake is insufficient.
3. Skin Hygiene
- Clean skin regularly with mild soap.
- Keep skin dry; manage incontinence promptly.
- Avoid scrubbing over bony prominences.
- Apply protective barriers for moisture.
- Use moisturizers to prevent dryness.
4. Repositioning
- Turn and reposition patients every 2 hours in bed.
- Avoid pulling patients (reduces shear injury).
- Use lifting devices if available.
The Braden Scale for Risk Assessment
The Braden Scale helps assess a patient’s risk of developing pressure ulcers. It evaluates six factors:
- Sensory perception (ability to respond to discomfort)
- Moisture (skin exposure to wetness)
- Activity (degree of physical activity)
- Mobility (ability to change and control body position)
- Nutrition (usual food intake pattern)
- Friction & shear (skin resistance against surfaces)
Scoring:
- Low Risk: 22–23
- Moderate Risk: 19–21
- High Risk: <18
Clinical Application: Patients should be assessed every shift to ensure timely interventions.
Quick Reference Table: Stages of Pressure Injuries
| Stage | Key Features | Depth Involved | Example Presentation |
|---|---|---|---|
| Stage 1 | Redness, intact skin, non-blanchable | Epidermis | Red patch, warm to touch |
| Stage 2 | Partial thickness loss, blister/ulcer | Epidermis + Dermis | Shallow ulcer |
| Stage 3 | Full thickness loss, crater-like | Subcutaneous tissue | Deep ulcer with edges |
| Stage 4 | Extensive destruction, exposed muscle/bone | Muscle & bone | Large, infected ulcer |
| Unstageable | Covered with eschar or slough | Unknown | Black, necrotic wound |
Frequently Asked Questions (FAQs)
Q1. What areas are most prone to pressure ulcers?
Common sites include the sacrum, heels, hips, elbows, shoulders, and back of the head.
Q2. Can pressure ulcers heal completely?
Yes, early-stage ulcers (Stages 1–2) can heal with proper care. Advanced ulcers (Stages 3–4) may require surgery or skin grafts.
Q3. How often should patients be repositioned to prevent ulcers?
At least every 2 hours in bed, and more frequently in chairs (every 15–30 minutes).
Q4. Why is nutrition important in ulcer prevention?
Adequate protein, calories, vitamins, and hydration improve skin integrity and support wound healing.
Q5. What is the role of eschar in unstageable ulcers?
Eschar (dead tissue) must often be removed (debrided) before proper staging and healing can occur.
