By Iosefina Dima (RGN)

Definition Terms
 Pressure ulcers are an  Pressure ulcer
injury that breaks  Bed sores
down the skin and  Pressure sores
underlying tissue. They  Decubitus ulcers.
are caused when an
area of skin is placed
under pressure.
 95% of pressure ulcers are preventable.

 Pressure ulcers cause patients long term pain

and distress.

 Treating pressure ulcers costs the NHS more

than £3.8 million every day.
 The time and money spent treating pressure
ulcers means some patients may not always
get the care they need.
 Is the national roll, It helps NHS teams in
their aim to eliminate harm in patients from
four common conditions:
 pressure ulcers
 Falls
 urinary tract infections in patients with a
catheternew
 venous thromboembolism (VTE).
 EPUA(2014)/PPIA – Prevention and treatament
of pressure ulcers. (Quick Reference Guide)
 NICE(2015) (Clinical guidline)
 DATIX – all pressure ulcers grade 2+ (grade
3+4 – serious incident)
• To understand the underlying structures of
the skin
• To gain a basic understanding of the process
of wound healing.
• To be able to identify different tissue types
in areas such as the wound bed, wound edge
and surrounding skin
Is it important to know the Structure and
functions of the skin?
 Largest and most
visible organ of the
body.

 1.Epidermis

 2.Dermis

 3.Subcutaneous
 PROTECTION of internal structures – physical
barrier.

 SENSORY perception- Allows feeling pain,

pressure heat, helps to identify potential
dangers and avoid injury.
 THERMOREGULATION- Blood vessels constrict
or dilate to raise or lower body temperature.
Sweat production promotes cooling

 EXCRETION -Transmits small amounts of water

and body waste via sweat. Helps to prevent
dehydration.
 METABOLISM-Photochemical reaction in the
skin produces Vitamin D essential for
metabolism of calcium.

 ABSORPTION-Some substances can be

absorbed directly into blood stream.

 COMMUNICATION
 Flattening of the dermal-epidermal
junction, increased susceptibility to friction/
shearing forces resulting in blistering.
 Decreased sensitivity to pain perception
 Epidermis becomes thinner and flatter ,
uneven distribution of melanocytes leading
to uneven pigmentation.
 Skin becomes wrinkled due to depletion of
elastic fibres.
 Skin becomes dry as a result of atrophy of
sebaceous glands
 INTRINSEC - Disease, medication, age,
dehydration/fluid status, lack of mobility,
incontinence, skin condition, weight.
 EXTRINSEC -Pressure, Shearing Forces,
Friction, Moisture.
 Imobility
 Nutrition (dehydration, obesity)
 Complience
 Co-morbidities
 Lack of equipment
 Infection
 Age
 Personal hygiene
 Lack of training (moving & handling)
 Knowledge of the skin
 Simple blanching test: press on the red, pink or darkened area
with your finger. The area should go white; remove the pressure
and the area should return to red, pink or darkened colour
within a few seconds, indicating good blood flow.
 Intact skin with non-blanchable
redness 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 (blue or purple).

 The area may be painful, firm,

soft, warmer or cooler as
compared to adjacent tissue.

 Category/stage I may be difficult

to detect in individuals with dark
skin tones. May indicate “at risk”
individuals (a heralding sign of
risk).
 Partial thickness loss of dermis
presenting as a shallow open
ulcer with a red pink wound bed,
without slough.
 May also present as an intact or
open/ruptured serumfilled
blister.
 Presents as a shiny or dry
shallow ulcer without slough or
bruising.*
 This Category/Stage should not
be used to describe skin tears,
tape burns, perineal dermatitis,
maceration or excoriation.

 *Bruising indicates suspected

deep tissue injury
 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. May
include undermining and tunneling.
 The depth of a Category/Stage III
pressure ulcer varies by anatomical
location. The bridge of the nose, ear,
occiput and malleolus do not have
subcutaneous tissue and
Category/Stage III ulcers can be
shallow.
 In contrast, areas of significant
adiposity can develop extremely
deep Category/Stage III pressure
ulcers.
 Bone/tendon is not visible or directly
palpable.
 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.
 Until enough slough and/or
eschar is removed to expose the
base of the wound, the true
depth, and therefore
Category/Stage, cannot be
determined.
 Stable (dry, adherent, intact
without erythema or fluctuance)
eschar on the heels serves as
‘the body’s natural (biological)
cover’ and should not be
removed.
 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.
 Deep tissue injury may be difficult to
detect in individuals with dark skin
tones.
 Evolution may include a thin blister
over a dark wound bed. The wound
may further evolve and become
covered by thin eschar.
 Evolution may be rapid exposing
additional layers of tissue even with
optimal treatment.
 Full thickness tissue 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. The depth of a
Category/Stage IV pressure ulcer
varies by anatomical location.
 The bridge of the nose, ear, occiput
and malleolus do not have
subcutaneous tissue and these ulcers
can be shallow.
 Category/Stage IV ulcers can extend
into muscle and/or supporting
structures (e.g., fascia, tendon or
joint capsule) making osteomyelitis
possible.
 Exposed bone/tendon is visible or
directly palpable.
 A moisture lesion as
‘reactive responses of the
skin to chronic exposure to
urine and faecal matter,
which could be observed as
an inflammation and
erythema with or without
erosion’
 Typically there is loss of the
epidermis and the skin
appears macerated, red
broken and painful
 Not over bony prominence
 Without necrosis tissue.
 Five simple steps to prevent
and treat pressure ulcers
Avoidable or Unavoidable?
 Critical illness
 Dementia/memory problems
 Spine instability
 Patient/resident not compliant with
treatment.
 Normal Wound Healing Response

 1. Haemostasis
 2. Inflammation
 3. Proliferation
 4. Maturation
• Starts immediately
after injury.
• Blood vessel
contraction
(vasoconstriction)
 Occurs between 3-5 days
 Redness, swelling,
warmth and pain
maybe present
 No infection
 Vascular permeability
increases and serrous
fluid ( comprising of
cell and plasma
protein) accumulates in
surrounding tissue.
 Occurs between 5-28
days
 Angiogenesis (new blood
vessels develop)
 Collagen synthesis
(protein fibers)
 Granulation formation
 Epithelialization
 Contraction
 For hypergranulation
tissue – pressure
dressing (foam)
 Occurs between 28 days to
1 year or longer
• Closure of wound and re-
epithelisation.
• Scar maturation
 Adverse local condition at the wound site.
 Age (increasing)
 Pathophysiological.
 Psychosocial influences.
 Inappropriate wound management.
 Adverse effects of other therapies.
 Biofilm is one of the most common reasons for
delayed healing in pressure ulcers.
 Biofilm occurs rapidly in wounds by keeping the
wound inflamed. Infection prevents healing of
pressure ulcers.
 Signs of pressure ulcer infection include slow or
delayed healing and pale granulation tissue.
 Signs and symptoms of systemic
infection include fever, pain, redness, swelling,
warmth of the area, and purulent discharge.
 Communication
 Breathing
 Diet
 Sleeping
 Environment
 Medication
 Pain
 Mobility
 Lenght
 Width
 Depth
 Wound location
 Measurements once a week/2 weeks.
Colour Physiological
State
Black Necrotic
Yellow Sloughy
Red Granulating
Pink Epithelializing
Green Infected?
Healthy tissue
Unhealthy tissue
Bright red
Dark red
Moist
Dehydrated
Shiny
Dull
Does not bleed
Bleeds easily
Clinical appearance
of
surrounding skin
 Quantity – Small ,  When does it occur?
moderate copious is  How bad (intense) is it?
dressing containing  How does the patient
exudate? describe it?
 Colour – Green?  What makes it better?
serous?,
haemoserrous?
 Consistency –
Thick?Thin,