A pressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure, shear, friction or a combination of these (EPUAP 1998). They are most likely to occur when a hard bony area covered by a thin layer of tissue is in contact with a hard surface, such as a bed, trolley, theatre table, wheelchair etc.
The body can withstand high interface pressures for a very short period of time. It is when the pressure is not regularly, relieved that damage occurs and a pressure ulcer develops. Elderly patients are particularly vulnerable because their skin usually becomes thinner and more fragile with age. Pressure sores can develop in a matter of hours. Decubitus ulcers can happen during hospitalization,
in a nursing home or in a community setting.

4 Stages of pressure sore development


The skin is essentially our largest organ and made from three distinct layers. The top surface called the
Epidermis which is rough and microscopically thin, this is constantly being worn away and replaced throughout our life span. Underlying the epidermis is viable dermis consisting of nerves, glands, fatty (adipose) tissue and muscle. Beneath the dermis is a subcutaneous layer of adipose tissue containing a large number of blood vessels.


Common Areas For sore Development
Unrelieved pressure on a specific area of the body (eg the heels , the hips) will affect the blood supply to the skin and underlying tissues causing that area to become damaged. Mild tissue damage results in skin discoloration, giving a brown or purple appearance. This may look darker if the skin is very fair.

More severe pressure ulcers can expose muscle and even bone. The area around the dead tissue will look red and inflamed and may become infected. This process, once occurred is extremely difficult to heal. The resulting wound can be very painful and can eventually lead to death. Most pressure sores can be prevented.


Stage One Pressure injury Early Sign


Sitting Position

Prone Position

Lateral Position

Lying Position

2.PREVENTING PRESSURE SORES(Skin Inspection & Repositioning)
Skin Inspection
Patients skin and pressure points should be inspected regularly. Each patient should have their vulnerable areas checked i.e. heel, sacrum, femoral trochanters any area which is in contact with pressure or where shear and friction are exerted. Patients should be encouraged to inspect their own pressure points where possible.


In order to prevent pressure ulcers developing, it is important that those who are immobile have their position changed at least every two hours.
This may need to be more frequent if sitting. Those at higher risk of pressure ulcers, such as the elderly and those with existing medical conditions should keep as active and mobile as possible.
Also important is keeping the skin clean and dry, and checking that bed linen is free from wrinkles.

Pressure reducing/relieving devices
There are many different types of support surfaces which can either reduce or relieve pressure.
Pressure Relieving mattresses come in many different forms and these are seen to reduce pressure.


Pressure relieving mattresses are made of rows of air cells, these cells inflate and deflate (alternate) sequentially in a set time period, this ensures that pressure on the body will be continually changing and areaˇ¦s of the body for a period of time will have pressure relief.
Pressure relieving mattress are controlled by a powered intelligent pump system, Most systemˇ¦s have features which enable the user to alter the comfort setting for patient.
Alternating Pressure relieving mattress's also can have small ventilated holes within the cells to gently allow air to escape to reduce any skin moisture and also to increase the comfort for the patient


The skin around the area will be red and shiny or dark purple.
The skin may be warm to the touch compared with nearby tissue.
The area may also be swollen or hard and may lack feeling.
Note: Skin reddening that disappears after pressure is removed is normal and is not a pressure ulcer. Discoloration of the skin that is constant may be a pressure ulcer.

Grade 1:
The skin is not broken but the color of the skin changes, purple or red. The irritated skin may feel warmer than the skin around it. At this stage, the pressure ulcer may be healed just by taking pressure off that skin area. Non-blanching hyperaemia / erythematic of intact skin demonstrates that damage is occurring (EPUAP 2001)

Grade 2:
Partial thickness skin loss involving epidermis, dermis or both superficial damage presenting as blister or abrasion (EPUAP 2001)
The skin may break or blister and the skin around it will look irritated and inflamed.

Grade 3:
Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia (EPUAP 2001)

Damage to the body tissue begins to develop and the sore becomes more than a surface wound as it affects the tissue underneath the skin. At this stage the sore will have a crater-like appearance.

Grade 4:
Extensive destruction tissue necrosis or damage to muscle, bone, or supporting structures with or without full thickness skin loss (EPUAP 2001)

The ulcer has eroded deeply, causing damage to body tissue, bone, muscle, tendons and joints. The risk of infection is much higher at this stage

Extensive destruction tissue necrosis or damage to muscle, bone, or supporting structures with or without full thickness skin loss (EPUAP 2001)

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