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Pressure Ulcers

Pressure ulcers are areas of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces; they may also develop from friction and shearing forces. Because muscle and subcutaneous tissue are more susceptible to pressure-induced injury than skin, pressure ulcers are often worse than their initial appearance.

Risk factors include age, impaired circulation, immobilization, malnourishment, and incontinence, sensory deficiency, and dehydration. Aging increases the risk, in part because of reduced subcutaneous fat and decreased capillary blood flow. Immobility and comorbidities increase risk further. Severity ranges from skin erythema to full-thickness skin loss with extensive soft-tissue necrosis.

Diagnosis is clinical and treatment may include pressure reduction, avoidance of friction and shearing forces, local care, and sometimes skin grafts or myocutaneous flaps. Prognosis is excellent for early-stage ulcers; neglected and late-stage ulcers pose risk of serious infection and nutritional stress and are difficult to heal. Pressure ulcers are staged to guide clinical description of the depth of observable tissue destruction.

The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original four stages and adding two stages on deep tissue injury and unstageable pressure ulcers. (NPUAP 2007) The prompt identification of at-risk patients using a validated risk assessment tool is essential for accurate, prompt identification of at-risk patients and timely implementation of prevention strategies.

The Braden Scale and the Norton Scale are probably the most widely used tools for identifying elderly patients who are at risk for developing pressure ulcers. Both tools are recommended by the Agency of Health Care Policy and Research (AHCPR) renamed the Agency for Healthcare Research and Quality, AHRQ).