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Pressure Ulcers: Prevention and Treatment

Pressure Ulcers: Prevention and Treatment

Jennifer A Gardner, PT, DPT, MHA, CWS

May 21, 2013

This text base course is a transcript of the live event titled "Pressure Ulcers:  Prevention and Treatment" by Dr. Jennifer Gardner, PT, DPT, MHA, CWS.  It is strogly recommended to follow along with the course handout to ensure understanding of the course material.  

>>Jennifer Gardner:  Thank you for joining us this afternoon where we will talk about pressure ulcers prevention and treatment. 

Why do you as a physical therapist need to know about pressure ulcers?  Even superman got a pressure ulcer!  As most of us know, Christopher Reeve had a spinal cord injury and subsequently developed a pressure ulcer.  When he passed away, it was actually due to complications from an infection in that pressure ulcer.  Sometimes we tend to think that it is only the elderly that get pressure ulcers or it is only people who are getting poor care that get pressure ulcers.  Unfortunately a pressure ulcer can happen to anyone who is in some sort of debilitated state (even for several days a pressure ulcer can result).  As I mentioned anyone can get pressure ulcers and it is something you can see in any treatment surrounding.  So while you may not actually be treating the pressure ulcer, it is important to be able to identify one, especially if you are providing rehab to the patient.  We know as physical therapists that we tend to spend the most amount of time with our patients.  If we are in a rehab or skilled nursing setting, we can be with the patient for an hour to two hours a day.  We might be the ones who help toilet the patient or while they are walking we might catch a glimpse of a pressure ulcer on their sacrum.  Maybe we put their socks on for ambulation and see a pressure ulcer on their heel.  Even if you are not treating the wound or the pressure ulcer yourself, you might be the one to find it. 


Dr. Courtney Lyder, in an article he wrote in the Journal of American Medical Association, said anywhere from  1.3 to 3 million adults develop pressure ulcers every year.  It is also important to note that 85% of patients with a spinal cord injury will develop at least one pressure ulcer at some point in their lives.  What I like to remind doctors and sometimes nurses or risk managers, when a patient’s skin breaks down, that is just like any other kind of organ failure.  If a patient is already in heart failure or respiratory failure or kidney failure, or a combination of any of those, they are also probably going to experience some type of skin failure.  Remember that the skin is our biggest organ, and when the rest of the body is shutting down, so does the skin.  That is when pressure ulcers result.  As I mentioned earlier, you need to be able to recognize pressure ulcers, and if you find one, make other members of the medical team aware as well. 

So what is a pressure ulcer?  Commonly referred to as a bed sore or a decubitus ulcer, but that is not the most appropriate term.  A bed sore indicates that the patient developed that sore while they were in bed, but as I already mentioned, patients can get pressure ulcers when they are sitting in a wheelchair.  Bed sore is not appropriate.  Sometimes it is also called a decubitus ulcer.  That was the old Latin term and it actually means to be lying down.  It is similar to the bed sore name, implying that a patient got it while they were lying down.  A pressure ulcer can develop in a wheelchair.  So the most appropriate name is a pressure ulcer.  But perhaps a better term for the cause instead of pressure is tissue load, because it is more than just pressure that contributes to these wounds.  Tissue loading is caused by pressure, friction, shear, and exacerbated by moisture and temperature.  We will go into that in a little more detail in a few more slides.  It is also important to remember that devices can cause pressure as well.  It might not just be the bed, it might not just be the wheelchair.  It could be casts, orthotic devices, oxygen tubing, compression stockings, restraints, bed pans, toilet seats, any kind of device if left in contact with tissue for long enough can cause a pressure ulcer.  While we are talking about old terms, I just want to throw in an old treatment that used to be considered appropriate.  That was to massage bony prominences.  The reasoning why they thought massaging the bony prominence was important was that it was a process of trying to toughen the skin as a means of increasing the tolerance of the tissue to that tissue load.  However this is now considered contraindicated and no longer appropriate because it could actually cause deep tissue damage. 

Figure 1.  Devices causing pressure ulcers

So real quick I just wanted to give some examples of devices that cause pressure ulcers.  As you can see here (in Figure 1), this gentleman was wearing a cervical collar and no one was taking off that collar frequently enough to assess his skin.  So when someone finally did take off the collar, they found that he had a necrotic area right here on his clavicle.  That is a pressure ulcer because it was caused by the pressure of the cervical collar.  Figure 1 also shows a gentleman before he got his trach, he was connected to the ventilator via an ET tube.  You can see here where that ET tube and the pulling of the adhesive, tape or string that was used to hold that ET in place put undue pressure on his cheek and caused this pressure ulcer.  Another example that you might commonly see as a physical therapist is where a knee brace causes a pressure ulcer.  Sometimes if the patients have decreased sensation, which we will talk about in a few minutes, they are not going to feel that pressure being caused and that is why they end up with these pressure ulcers.   Another example (Figure 1) where they had a pulse oximeter probe on this gentleman’s ear and it caused breakdown.  Just keep in mind how important it is to do frequent skin checks when patients have any type of device, whether it be a brace or a neck collar, or any kind of device that can come off and be put back on so that you can frequently check the skin and make sure no pressure ulcers are resulting.  Unfortunately in the example of a cast, it is not so easy to take off that cast and do the skin inspection, and that is why sometimes doctors are surprised when they take the cast off to find a pressure ulcer.  Because the patient did not have sensation, they did not feel the pain that was resulting, and they were not able to tell the doctor that they needed the cast removed.  Education of the patient, other staff members, as well as the family to do frequent skin checks is of utmost importance. 

Pressure ulcers – Why are they such a big deal?  It is because there is a huge cost to treat these wounds.  It can cost up to $40,000 minimum for a stage IV pressure ulcer.  By the time they go to the operating room for debridement, by the time they get specialty treatments for the wound, they get specialty beds, specialty cushions, it really does add up.  Another concern for health care facilities, especially hospitals, was the Centers for Medicare and Medicaid (CMS) decided in 2007 that any condition that developed while a patient was in the hospital would not be reimbursed.  Pressure ulcers are not the only condition.  UTI, surgical site infection, wrong side surgeries, there is a whole bunch of conditions that CMS has now decided are “never” events and they should not occur while a patient is under the care of a hospital facility.  So as you can imagine a hospital stands to lose thousands or even millions of dollars if they are not properly documenting when patients come in with pressure ulcers.  It is very important that nurses do a thorough assessment at admission to capture any pressure ulcers that are present on admission so that the hospital will actually get reimbursement for that condition.  There is some debate about how long you have after a person is admitted to actually capture a present on admission diagnosis.  There was some indication at first that they were saying within 24 hours it had to be documented, but I think they are a little more lenient now that as long as it is documented during the hospital stay, then you will get reimbursed.  However that is a hard thing to prove because how do we know it did not result in the hospital and now they are just claiming it is a "present on admission pressure ulcer".  We will talk a little bit later on in the presentation about things you can do to make sure that you prove a pressure ulcer was present on admission.  I just want to emphasis how important it is for any of these conditions to be properly documented as present on admission so that hospitals will get the reimbursement they are entitled to. 

Figure 2 Pressure Ulcer

Pressure Ulcer Stages, Locations, Etiology and Contributing Factors

Now we will go into pressure ulcers, pathophysiology and prevention.  This is a photo I use frequently for the shock value (Figure 2), but it is important to see that often patients get numerous pressure ulcers.  So you are not just going to see one on the sacrum, or maybe one on a heel, you are going to see a number of them.  In this particular patient, he was a paraplegic, he had bilateral above knee amputations as you can see the way he is laying, and he is putting pressure on the distal ends of his residual limbs.  He was not compliant with the plan of care.  So you can see he not only got a sacral pressure ulcer from when he was lying supine, but then he also got a left ischial tuberosity pressure ulcer and a right ischial tuberosity pressure ulcer.  Then because he still was not compliant and was sitting on the wrong type of surface, he got breakdown of his perineal region and also his scrotum.  As you can see, the Foley catheter goes into the tip of the penis, but then you can see it coming through the skin and tissue before it goes back into the bladder.  This obviously is an extreme case.  This is not a typical patient that you would see, but it is something that you might see especially if you work in an inner city hospital where patients do not always have the resources to get the surfaces they need. Sometimes they are very suspicious of physicians and hospitals, and they will not come in until they are very sick.  This guy was also a drug user so his priority was not his pressure ulcer.  His priority was getting his drugs and consequently he ended up passing away from complications from the pressure ulcers. 

Figure 3 Pressure ulcer gradient

The National Pressure Ulcer Advisory Panel defines a pressure ulcer as any lesion caused by unrelieved pressure resulting in damage of underlying tissue.  It is important to remember that the less soft tissue present, the more pressure that is exerted.  If you think about ears, heels, sacrum, and occiput, there is not a lot of soft tissue covering those areas.  Those bony prominences will be more prone to pressure ulcers and skin breakdown.  I want to demonstrate here the pressure ulcer gradient (Figure 3).  So the pressure starts at the top of the figure and then it ends up causing deeper damage at the bony interface then at the superficial tissue.  So the pressure is greatest at the bony prominence and gradually lessens in a cone-shaped gradient to the periphery.  So sometimes by the time (we will go into this a little bit later) you actually see damage at the dermis, the damage is already pretty severe at the bony interface. 

In an article quoted in the Comprehensive Wound Management text book written by Glen Irion, he talks about the use of high resolution ultrasound.  This study demonstrated that 80% of patients with an abnormal appearance of subcutaneous tissue suggestive of deep tissue injury did not have any erythema or redness documented.  So this strongly suggests that the injury occurs first in the deep subdermal tissue or at the bony interface, and then progresses through superficial dermal tissue before the injury can actually be seen at the skin level.  This study also found that dermal edema was only apparent once the damage was done subdermally.

Figure 4 Levels of breakdown

There are four levels of skin breakdown (Figure 4).  The first level is hyperemia.  This can be seen within 30 minutes, usually appears as redness, and if you change the patient’s position and alleviate the pressure, usually the redness will be gone in approximately an hour.  Ischemia is where the tissue is starting to not get the blood flow it needs and that is when it can start to cause some skin damage.  This occurs after two to six hours of continuous pressure and may actually take up to 36 hours to be alleviated once the pressure is removed.  It can be reversed.  The next level is necrosis.  This occurs after 6 hours of continuous pressure.  The skin may turn blue or gray and may become indurated or firm.  This necrosis may or may not disappear once the pressure is removed, and would actually lead to the ulceration which is level IV.  Ulceration may occur within two weeks after necrosis and you may get potential infection.  However it is important to keep in mind that it does not take up to two weeks for these pressure ulcers to occur, and we will talk about that in a future slide. 

Figure 5 Progression of a pressure ulcer

Figure 5 is just to demonstrate the progression of a pressure ulcer.  You can see they used the old term there of decubitus ulcer.  The damage has begun at the bone, muscle, and tendon which is where the pressure is greatest, but the pressure has to go through all this skin, fat, and subcutaneous tissue before it gets to the muscle and tendon.  So in this picture you start to see some of that black or gray tissue occurring.  You are starting to see some erythema and redness in the subcutaneous tissue, and more pressure is being put on the muscle and tendon. 

Then we come down to the bottom left picture.  We actually have some ulceration occurring, more damage to the subcutaneous tissue, until finally we get to the bottom right photo which is a stage IV where now the subcutaneous tissue is gone, the muscle and tendon has been broken down, and now the bone is exposed. 

Figure 6 Time vs pressure graph

Subcutaneous fat and muscle are more sensitive to ischemia and tissue breakdown than skin.  This is because muscle and fat tissues are more metabolically active, so they require more of the blood flow to get there, more of the cells to get there and keep it active.  If there is any type of ischemia going on, that is going to breakdown the muscle and fat tissues.  Figure 6 will demonstrate it does not have to be high pressure over a short time; it could actually be low pressure over a long period of time that can produce pressure ulcers.  If we see here in this graph, on the left is the skin pressure applied by mmHg.  So we go from 100 mmHg all the way to 600 mmHg.  Then we look at hours.  If we have high pressure, we can see skin damage within one to two hours.  If we have lower pressure, we can start to see skin damage maybe at about the 10 or 12 hours.  It does not have to be just sitting on something, say lying on a stretcher in the ER for an hour or two.  Yes that will cause a pressure ulcer, but even if they get up to the floor and they are on just a foam mattress and they are not turning at all, you will see damage that can occur within 10 to 12 hours from a lower amount of pressure, but a longer period of time. 

So how can we identify pressure ulcers?  They are actually fairly easy to detect in lighter pigmented people, and we will see that in some pictures coming up.  But it can be difficult to tell when damage is being doing in a darker pigmented person, and sometimes you need to look for other skin changes besides the color of the skin.  Sometimes you will look for changes in skin temperature and sometimes it will be changes in skin texture.  The temperature might be warmer because you are getting some inflammation at that area.  The temperature might actually be cooler because you are getting some ischemia and it is not getting any blood flow.  The texture might be a boggy or spongy kind of feeling when you press on the tissue, or it actually might be hard or indurated.  You need to compare the affected side with the unaffected side to see where the differences are noted.

I want to go back to this slide talking about the high resolution ultrasound.  The pressure ulcer will typically start out as round from the bony prominence and then it will change shape as it deteriorates due to friction and shear.  As this study is implying and pointing out, the injury cannot always be seen with the eye, but with ultrasound it can be seen that there might be some abnormal appearance of the subcutaneous tissue and superficial and deep subdermal injury before you will see it at the epidermal layer.  With this study and with other similar studies that are out there, ultrasound is now being used more frequently to detect skin damage and to see the extent of the skin damage.  When a patient presents with a pressure ulcer, (if you have this Hi-Res ultrasound in your clinic), you could actually ultrasound the surrounding tissue to see how deep the extent of damage is actually occurring, because what you see with the naked eye does not always tell the whole story.

Now we will go back to clinical presentation of a pressure ulcer.  It is usually a pretty predictable cutaneous chain of events.  The first sign of trauma that you will see is blanchable erythema which is when you press on the redness of the skin, it will turn white.  Then as soon as you alleviate that pressure, it will go back to being red.  Other signs might include some edema and some temperature elevation as I already mentioned.  However as the damage continues, you are going to get nonblanchable erythema which is where if you press on that redness, the redness will not go away. It will not turn white and it will just stay red.  This is actually part of the definition of a stage I pressure ulcer.  As we mentioned in the levels of the skin breakdown, a stage I or this redness can actually be resolved if properly treated within two to four weeks without further deterioration of the skin. 

Where are pressure ulcers commonly located?  Anywhere there are bony prominences.  The ears, the occiput, the shoulder, scapula, elbow, iliac crest, sacrum, trochanter, ischium, medial malleolus, lateral malleolus, lateral edge of the foot, great toe, heel, anywhere there is pressure you have a pressure ulcer.  However it is interesting to note that more than 95% of pressure ulcers occur over five locations.  The most common being the sacrum, and then the heels, and then the hips, the ischial tuberosity and the lateral malleolus.  The problem with pressure ulcers on the heels and the lateral malleoli is they are often complicated by peripheral vascular disease.  Typically these patients are so debilitated that they are in the hospital and they are not moving around well.  They do not usually have just one diagnosis and they usually have multiple co-morbidities including diabetes, and usually an important association with diabetes is peripheral vascular disease.  They might not be getting good blood flow already to the heel and the lateral malleolus, and then if you put unrelieved pressure in the mix the result is sure to be pressure ulcers. 

If anyone was on my presentation two weeks ago, I talked about arterial wounds and how the most important thing to do with arterial wounds is to get a vascular consult to make sure that they have adequate blood flow. If they do not have adequate blood flow they need to get the interventions needed to heal the wounds and get the blood flow to the area.  Same thing with a pressure ulcer on a heel or lateral malleolus.  It is important to ask the doctor to get a baseline ankle-brachial index or a baseline arterial Doppler of the lower extremities to make sure that they have good vascularity so that when we get the pressure off the heels, they have enough blood flow to the heel that they can actually heel the pressure ulcer. 

Figure 7 Positions and effect on pressure

So here is just some diagrams in Figure 7 of how in different positions different areas can have pressure.  So in supine, it could be the occiput, the scapula, elbows, the sacrum and it could be heels.  A lot of times we will actually see friction and shear damage to the elbows because patients tend to dig in their elbows to try and scoot up in the bed.  They will get a combination of pressure, friction, and shear damage to that elbow.  In the prone position, it could be the toes, the knees, the genitalia, the breasts, the acromion process, the cheek and the ear.  Now fortunately most of the time our patients are not prone.  We do not place patients in prone generally, but if someone had been on the floor at home from a fall and no one was around to help them, they may have laid on the floor for several days before they were found. These are places you might actually see pressure ulcers on these people especially if they come in with rhabdomyolysis (so their blood work is demonstrating some kind of muscle damage), then it would be very important to do a thorough skin assessment to see where they might have some skin damage from lying on the floor. 

In the side-lying or lateral position, it will be the malleolus, the medial and lateral condyles, the greater trochanter, ribs, the acromion process, and the ear.  In this side-lying position, it is important to put a pillow between the knees so that you lessen the amount of pressure that is caused in side-lying.  This is just another of the same document.  The bottom right corner of Figure 7 demonstrates the main ways that pressure sores arise.  Pressure, shearing and friction.  We will talk about the definition a little bit more in a minute, but when the patient slides down in the bed, that is what causes tissue damage to occur. 

Figure 8 Medial foot pressure ulcer

Here are just some examples of pressure ulcers.  Figure 8 is actually on the medial foot at the first metatarsal head.  This is actually bone sticking out.  This woman most likely had a bunion all her life, and then when she became debilitated someone probably put her in side-lying. They did not make sure to adequately relieve the pressure over that area and she actually got a pressure ulcer on that bony prominence.  Here is a sacrum in Figure 9.  You can see that it did probably start out round, but now it is more oval because of friction and shear damage.  Figure 10 is an ear.  Again, this was probably caused by a pulse oximeter probe that was put on the ear.  It is also important to remember that patients can get pressure ulcers right between the ear lobe and the skull because of oxygen tubing.  That is something we found at my facility a couple of months ago.  We had a couple of patients breakdown with pressure ulcers right behind their ear from their oxygen tubing.  It was just because no one was really looking there because it was not a common area for pressure ulcers.  But when you think about it and as I have mentioned devices can cause pressure ulcers, you have to make sure to assess all areas of the skin.  As a corrective action plan, anyone who is at risk for pressure ulcers now gets special foam tubing to go around the oxygen tubing to help protect the ears from pressure. 

Figure 9 Sacrum

Figure 10 Ear pressure ulcer

Figure 11 Sacral pressure ulcer

Figure 11 is a sacral pressure ulcer.  You can see that it is very extensive.  Right now, we will go through definitions, but it is considered unstageable because you cannot see the wound base.  This person unfortunately did have surgery a few weeks before this picture was taken, and you can see where they had retention sutures in their skin after the debridement was done.  This particular surgeon thought that she could debride a pressure ulcer and then close it up like she would an abdominal incision or some other typical incision.  It is important to understand that pressure ulcers have to heal by granulation and they have to fill in from the bottom up before they can heal.  Unfortunately when this lady was discharged back to the nursing home with these retention sutures, the tissue that was already necrotic, continued to necrose and continued to breakdow.  She came back in with this much bigger deeper wound.  Subsequently before she could go back and have it debrided again, she passed away. 

Figure 12 Retention sutures in surgical debridement example

Here is another example of that same doctor in Figure 12.  She debrided the wound which actually at the time when she took the patient to the OR was only about a 1 x 1 pressure ulcer.  She debrided the wound and then primarily closed it which leaves a hole inside the wound where the tissue can now necrose again and lead to worse problems.  Here again you can see these retention sutures.  So she closed the wound with staples and retention sutures when these wounds should be allowed to fill in by secondary intention of filling in with granulation tissue first, and then closing up with skin or with a muscle flap or skin graft to completely close the wound all the way.

Figure 13 Deep tissue injury

Now we will talk about the definitions of the stages and it is by the depth of tissue injury observed.  It does not necessarily take into account the damage that cannot be seen.  That is one limitation of this staging system.  It is also important to remember that staging is only using for pressure ulcers.  It is not used for any other type of wound.  These are just meant for pressure ulcer wounds.  There are four stages and two classifications.  We will go into them in more depth now. 

The first classification is a deep tissue injury.  This is a purple or maroon localized area of discolored, intact skin or a blood-filled blister that is due to damage of underlying soft tissue from pressure and/or shear.  As I mentioned, you might look for tissue that is firm, mushy, boggy, warmer or cooler as compared to the adjacent tissue.  Deep tissue injury can be very difficult to detect in individuals with dark skin tone, and it may only present as a thin blister and then within a day or so, it is a big wound.  This is because it was hard to see that damage was occurring.   An example of a deep tissue injury is seen on this slide (Figure 13).  So you see the purplish appearance.  The skin is still intact.  There is no breakdown of the skin here, but it does have that purple or bruised appearance.  As I mentioned earlier in the patients that have been found down on the floor at home and no one really knows how long they were there, they may come in with this bruised appearance and someone may incorrectly assume that it is just a bruise from the fall.  No it is actually must worse than that.  It is a deep tissue injury that will most likely progress to a stage III to IV pressure ulcer with a couple of days.  Here is deep tissue injury on the heel in Figure 14.  You can see that this presents as a blood-filled blister and a little bit of deep tissue damage right here. 

Figure 14 Deep tissue injury of the heel

Figure 15 Evoling deep tissue injury

Figure 15 is actually an evolving deep tissue injury.  Here you can see there is still some just deep tissue injury, but the skin is no longer intact.  Any time there is slough in the wound, which is this yellow necrotic tissue then the wound is automatically a stage III pressure ulcer.  Not to say that it cannot go down to a stage IV, if definitely can; but if you see slough in any wound, it is at least a full thickness, but specifically in a pressure ulcer it is a stage III.  This is important to document, when you admit a patient like this, or if you are evaluating a patient with a deep tissue injury, it is important to document in your note that this patient has a deep tissue injury and it is suspected or assumed that the damage will continue to evolve and the patient will present with a stage III or IV pressure ulcer in the next several days.  What this does is protects the facility that is admitting the patient because you are documenting that you are seeing this wound when they came in, but it is also saying that this wound is going to become a III or IV very shortly no matter what we do because the damage is already done.  That way when CMS comes back and reviews the notes, they can see that the hospital did not give the patient that stage III or IV, but that they were actually admitted with the damage that caused that stage III or IV. 

Stage I pressure ulcer is an observable pressure related alternation of intact skin.  Deep tissue injury and stage I both are intact skin.  With  a stage I, you look at those indicators again such as skin temperature, tissue consistency and/or sensation to determine a stage I.  While it may present as redness in lightly pigmented skin, in darker skin tones it may actually look red, blue or purple. 

The National Pressure Ulcer Advisory Panel came out with updated definitions in 2007.  So the first definition I will give you is the older definition, and then this is the more current definition.  Intact skin, nonblanchable redness or erythema of a localized area, usually over a bony prominence.  You might not have visible blanching in darker skin, but its skin color differs from the surrounding areas.  Seeing any kind of stage I indicates an at risk person.  They are at risk for further skin breakdown and need to be watched carefully to make sure no pressure ulcers occur.  Here is an example of a stage I pressure ulcer on an ischial tuberosity in Figure 16.  It is redness, and when you would push on that redness, it would not turn white, but it would stay red. 

Figure 16 Stage I pressure ulcer

Stage II.  This is the old definition.  A partial thickness skin loss involving epidermis and/or dermis.  It is superficial and presents clinically as an abrasion, blister, or shallow crater.  It is painful.  The updated definition is partially thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough.  It may also present as an intact or open ruptured serum-filled blister.  If you see a blood-filled blister, that is a deep tissue injury.  If you see a serum-filled blister, that is a stage II.  Very important to keep in mind that stage II should not be used to described skin tears, tape burns, perineal dermatitis, maceration or excoriation.  A lot of times we will find that patients have skin breakdown in their perineal area around their rectum and nurses or medical professionals are staging it as a stage II pressure ulcer.  It is not.  It is actually incontinence-associated dermatitis.  It is coming from severe diarrhea.  It  is coming from severe incontinence of either urine or feces.  So they should not be staged because they are not pressure ulcers.  However they do have similar tactics for prevention and treatment because if someone has perineal dermatitis and their tissue is already compromised, they are going to be at increased risk for pressure ulcer development.  We will talk a little bit more about what to do when people are at risk for incontinence issues, but basically it is frequent toileting, use of barriers such as dimethicone lotion or some cloths that actually come with dimethicone in the cloth and that you just protect that skin as much as possible from any feces or urine. 

Figure 17 Stage II

Here is an example of a stage II pressure ulcer in Figure 17.  You can see the top layer of skin is no longer there, but there is really no depth to the wound.  It is fairly superficial.  This gray area is actually new healing skin.  That is what it will look like in darker pigmented people and then it will eventually fade to a more normal color, or more natural color for them. 

Stage III.  This is full thickness skin loss involving damage or necrosis of subcutaneous tissue, and may extend down to, but not through underlying fascia.  It is usually not painful because the nerve endings are no longer intact.  The new definition is full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon and muscle are not exposed.  Slough may be present but does not obscure the depth of tissue loss or the wound base.  If you can see part of the wound bed, then you can stage it as a stage III.  However if it is mostly covered with necrotic tissue, then you would call it unstageable.  A stage III may include undermining and tunneling.  And one very important fact to remember is the depth of a stage III pressure ulcer varies by anatomical location.  The bridge of the nose, the ear, the occiput, and the malleolus do not have the same subcutaneous tissue as other areas such as the buttocks.  So stage III ulcers will be very shallow in these areas.  However areas of significant adiposity such as the buttocks can develop extremely deep stage III pressure ulcers that still will not have bone, tendon, and muscle exposed, but just because of the deep layer of subcutaneous tissue it will be a deeper stage III. 

Figure 18 Stage III

Figure 19 Small amount of slough

Figure 20 Occiput

Here is a stage III (Figure 18).  It does have some depth to it.  Another one (Figure 19) has a little bit of slough, so you know it is a stage III.  Here is one on the occiput  (Figure 20)   Again you see some slough, but you also see some granulation tissue. 

Finally a stage IV pressure ulcer is full thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, or supporting structures, and again not usually painful.  Slough or eschar may be present, but again you need to be able to see some of the wound bed.  As it is for stage III, a stage IV on any of these more shallow areas such as the bridge of the nose, the ear, the occiput, and the malleolus, as they do not have subcutaneous tissue, those ulcers will be very shallow.  Stage IV ulcers can extend into muscle and/or fascia, tendon or joint capsule which makes osteomyelitis or a bone infection possible.  Here is an example of an unstageable or a stage IV, but you can see part of the wound base, you can probably palpate bone .  This is considered a stage IV(Figure 21).  Figure 22, while the wound base is mostly covered with necrotic tissue, bone is exposed.  Once bone is exposed, then you know it is a stage IV pressure ulcer. 

Figure 21 Stage IV pressure ulcer

Figure 22 Bone exposed=Stage IV

The last classification is unstageable.  As I mentioned, you cannot accurately stage a wound if the wound base is not visible, and it can either be covered with eschar or slough.  Eschar is dry, leathery black tissue.  It is strongly adhered to the wound base and usually indicates an older wound that has not been well taken care of.  Slough is nonviable tissue that is loosely attached and it is usually more mucous-like and stringy than eschar.  The update definition of unstageable is a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar, and until enough slough and/or eschar is removed to expose the base of the wound, then the true depth and stage cannot be determined.  Most of the time if you see eschar, you are going to want to debride it.  We will talk about different types of debridement in a few minutes.  But the only time you would not want to debride eschar is if there is stable eschar on the heels.  Stable eschar is considered dry, adherent, intact eschar without any redness or fluctuance, the boggy or spongy feeling on the heels.  Basically the National Pressure Ulcer Advisory Panel’s recommendations are that if you see stable eschar on the heels, leave it alone.  Do not remove it, because this serves as the body’s natural or biologic covering.  Eventually that eschar will fall off and you will have a healed wound under that eschar. 

Here are some examples of unstageable pressure ulcers (Figure 23).  This is a sacral unstageable wound before debridement (on the left).  So you cannot really see any of the wound base, and then after debridement (on the right).  It does have some granulation, still some slough, but it is heading towards getting healthier looking.  This is an example of a pressure ulcer on the occiput at the bottom of Figure 23.  So just looking at this, you can imagine how long this person must have been lying.  If they were at home, they might not have lying for very long, but if they were on a hard floor, that pressure causes extensive damage.  It is very important to inspect all body parts upon admission.  Figure 24 are examples of eschar.  Top and bottom is on a heel.    Right picture is a hip.  This would be stable eschar.  This should be left intact until either it sloughs off, or you begin to get some pain or some redness, the eschar starts to pull away from the edges.  Then you would start debriding it.  Figure 25 is just examples of slough, just yellow, kind of stringy tissue. 

Figure 23 Unstageable pressure ulcer

Figure 24 Examples of eschar

Figure 25 Examples of slough

One last type of pressure ulcer that I want to talk about is a Kennedy terminal ulcer.  This was actually named after the nurse that discovered it,  Karen Kennedy.  A Kennedy terminal ulcer is commonly seen in terminally ill patients, and it is essentially unavoidable skin breakdown or skin failure that occurs as part of the dying process.  Kennedy terminal ulcers are always on the sacrum.  They can be shaped like a pear, butterfly or horseshoe.  They can be red, yellow, black or purple.  The borders are usually irregular and there is usually a very sudden onset.  So a patient deteriorates very quickly.  These are usually seen in the ICU or in hospice patients.  It initially presents as a blister or stage II.  It quickly deteriorates to a stage III or IV.  In the beginning it will look much like an abrasion, but then it slowly becomes deeper, turns color, turns from red-purple to yellow and then black.  How is it different from a regular pressure ulcer?  It typically starts out a lot larger, usually more superficial initially and develops rapidly in size, depth, and color.  It is just skin failure, just like the heart fails, the lungs fail, the skin also fails.  These are not the best pictures of Kennedy Terminal ulcers seen in Figure 26, but you can see they are on the sacrum.  One has a little bit of a butterfly shape, but what is most characteristic is it is just a really sudden onset in a terminally ill patient.  When you see that, death is probably eminent within a couple of days. 

Figure 26 Kennedy terminal ulcers

Finally one that is not real common, but it is out there, are closed pressure ulcers.  They are unique and potentially life-threatening.  They begin when there is a shearing force that causes ischemic necrosis in subcutaneous tissue, but you do not see any surface defect.  In time, there is inflammation in that necrotic tissue and then that causes a small ulcer, but has a lot of drainage.  You cannot really stage it.  It needs to be surgically debrided to see how far the tissue damage goes. 

In years past, nursing homes used to be made to reverse or backstage pressure ulcers.  Insurance companies wanted to see that a stage IV pressure ulcer was improving and becoming a stage III.  But now this is recognized as not being acceptable practice because once the damage is done to the skin, it is not going to regenerate that same skin.  Once a pressure ulcer is a stage IV, it will always be a stage IV because the damage has been to the muscle, tendon, and bone.  It will not progress from an IV to an III.  Once an ulcer is staged, it cannot change to go to a lower level, meaning it cannot go from a stage III to a stage II.  However it could go to a stage II from a stage III or IV.  But the correct terminology is actually a healing stage II or a healing stage III.  That demonstrates that the wound is improving but it is still that stage that it was before. 

This is just a nice tropical picture (in the handout) that I am sure we all wish we were there right now.  But we are not, so we will continue on. 

What are some risk factors for pressure ulcers?  There are extrinsic factors and intrinsic factors.  We have touched on some of the extrinsic factors such as pressure, shear, friction and moisture.  We will go into more depth with the shear and friction in a minute.  Some intrinsic factors or internal factors include nutrition, age, medical condition, psychological factors, immobility, inactivity, and decreased sensory perception.  This diagram (Figure 27) shows how all these things contribute to a pressure ulcer developing.  Incontinence kind of goes in between.  Yes it is an extrinsic factor because the urine and the feces are going on the external surface of the skin, but it is an intrinsic factor because it has something to do with the patient’s bodily function or lack of function.  Excessive pressure, friction, and shear forces, some kind of impact injury, moisture and posture, and then the intrinsic are immobility, sensation loss, age, disease, body type, poor nutrition, and infection. 

Figure 27 Factors contributing to ulcers

Let’s just talk about shear and friction.  What is the difference?  Shear occurs when the patient’s head of bed is elevated greater than 30 degrees.  Basically the patient’s skeleton starts to slide down towards the foot of the bed, but the skin stays in place.  This explains why wounds are not just round and the size of the bony prominence that they are over, but why they are usually oval.  Because you get tissue damage kind of being stretched superiorly and inferiorly.  Shear has the same effects as friction, but also there is blood vessel damage that can result in tissue ischemia.  Therefore shear usually causes deeper tissue damage than friction.  Friction on the other hand occurs when two surfaces move across one another.  So say you are moving a patient from the stretcher to the bed and you pull them over on the sheet.  If the sheet moves across the skin then you will cause friction and damage to the skin.  So think of shear as being more of an internal/external damage, and friction is more is two external surfaces rubbing against each other. 

Here is an illustration (Figure 28) of shear and you can see if the skeleton moved down, but the skin stayed up, then the skin is going to get damaged and can be torn.  Here is an illustration (Figure 29) of how the pressure ulcer probably started out like this, but then because of shearing we started to get some damage.  It is no longer just a round pressure ulcer, but an oval one. 

Figure 28 Illustration of shear

Figure 29 Ulcer size increased due to shearing

Then here is friction (Figure 30).  It could be the whole patient, say the heel is rubbing against the mattress or the sheet that could cause friction.  If the sheet is rubbing on the toes, that is friction.  But then shearing damage is more when the internal moves, but the external skin does not. 

Figure 30 Illustration of friction

Assessing Risk

Now let’s talk about some ways to determine who is at risk for pressure ulcers.  There are several different risk assessment scales available that nursing uses to identify a patient’s risk.  Three we will touch on briefly are the Braden, the Norton, and the Gosnell.  The Braden looks at sensory perception, moisture, activity, mobility, nutrition, friction and shear.  If a patient gets a score of less than 18, then they are considered to be at increased risk of skin breakdown.  The Norton scale looks at physical condition, mental state, activity, mobility, and incontinence.  Then Gosnell’s is a lot like Norton’s, but it adds a couple more things.  This slide (Figure 31) actually shows the Waterlow scale as well, but we are not going to talk about that one. 

Figure 31 Instruments for pressure ulcer risk

The Braden has subscales with scores of 1 to 4, and then 1 to 3 for friction and shearing.  The lowest score is a 6, the highest score is a 23.  The lower the score, the higher the risk.  The cutoff is 18 for adults and 16 for younger clients.  High risk would be 8 to 13, lower risk would be 14 to 18.  It has pretty good specificity, 100% positive predictive value. 

The Norton looks at physical condition, mental state, activity, mobility and incontinence, and again the score can range from 5 to 20 and a lower score means higher risk.  It has a good positive predictive value as well.  The Gosnell adds in more of the mental status subscale. 

We are going to talk a little bit more in depth about the Braden and I know it is a little hard to see, and you do not have Table 7.4.(Figure 32)  I apologize that was from a previous lecture.  We are going to go into what some of these subscores are and what interventions we can provide based on the subscore.  For example, the sensory perception goes from completely limited where the patient is unresponsive to painful stimuli to no impairment where they respond to verbal commands and they have no sensory deficit which would limit ability to feel or voice pain or discomfort.  Moisture ranges from constantly moist to rarely moist.  Activity from bedfast to walks frequently.  Mobility from completely immobile to no limitations.  Nutrition very poor to excellent, and friction and shear from a problem to potential problem to no apparent problem. 

Figure 32 Braden Scale

This is just another illustration of the Norton in Figure 33.

Figure 33 Norton Scale

So based on these subscores of the different scales, then interventions can be initiated to address each individual subscore.  While it is great to initiate these interventions, if it is not documented that we provided the interventions, then it is really pointless.  It is extremely important to document any interventions provided because we all know that old medical adage, “If it wasn’t documented, it wasn’t done.”  We could say, “I turned Mrs. Smith every two hours without fail.”  But when she gets a pressure ulcer and her family sues that hospital, if there is no documentation to show that you were turning that patient, then basically it shows that you did not turn them at all.  So as I mentioned, documentation will help in legal cases, especially to prove that a pressure ulcer may have truly been avoidable.  If the documentation reflects that you did everything possible to prevent that pressure ulcer, but the patient was just truly so sick that it was unavoidable, then chances are that you are going to get reimbursed because of the patient’s co-morbidities and level of sickness.


When looking at these interventions, you might not need to address all of the subscores.  For example, if a patient does not have an issue with moisture and incontinence, then you can skip that intervention and just move on to the others.  But they still could be at increased risk because of mobility, nutrition, friction and shear.  So you want to make sure that the interventions address the problems that the patient has. 

We are going to talk real brief about sensory perception.  So when individuals with normal sensation such as the people on this call, you are probably sitting in your chair now and starting to feel some effects of pressure.  But we are fortunate enough that we have the sensation needed to readjust.  So if you start to feel like your tailbone is hurting or your ischial tuberosity is hurting, then you will scoot around in the chair to take pressure off that area.  In individuals with normal sensation, repositioning will occur once the tissue insult is caused because the nociceptors pick up on it.  However in patients with impaired sensation, those nociceptors will not detect the tissue injury.  They will not reposition themselves and then tissue damage will occur.  If this is a problem for the patient, the interventions may include providing routine skin care, teaching the patient and the family the importance of changing positions frequently, establishing a turning schedule while the patient is in bed, elevating the heels off of the bed, making sure the head of the bed is at or below 30 degrees so you do not get that shearing damage.  You can elevate it for meals, but you want to make sure to lower it within one hour.  You also want to make sure to elevate the knee area 10 to 20 degree to prevent the shearing.  A lot of times in the ICU, you will come across issues with the head of the bed.  The physicians and the nutritionist will want the head of the bed much higher than 30 degrees because they do not want pneumonia to occur and they do not want aspiration to occur.  But then the skin team people will want it below 30 degrees so that we do not get that shearing damage.  Sometimes there has to be a compromise for everyone to agree that about 30 degrees is okay, but not anymore except for meals. 

If a person is wheelchair bound, you want to make sure that they weight shift in the wheelchair every 15 minutes or so, and limit their time spent in the wheelchair to one or two hours at a time.  While the patient is in bed, make sure to use a draw sheet to lift or turn to decrease the chance of any friction damage. 

Moisture.  Again if the patient is continent, they are not having any problems with toileting, you can get a bedside commode, and they can get themselves off and on the commode, which is great.  Just make sure that you educate the patient to call for help if needed and just assess their skin routinely.  However if moisture or incontinence is an issue, then you want to consider the following interventions.  You want to determine the cause of the moisture, provide incontinence care after each episode.  This could be pH balance cleansers, a protective ointment, it might be absorbent briefs, and it might be catheters even though they do not like to put catheters in, but again sometimes it is a compromise.  What is causing the most risk, them being incontinent and having skin breakdown or them perhaps being set up for a UTI?  You have to compare the risks and benefits of different treatments.  If an ulcer may be affected by incontinence, you will want to use a semi-occlusive dressing that is waterproof so that the incontinence does not get into the wound.  Again keep the head of bed at or below 30 degrees.  Consider fecal or urinary incontinence containment devices.  There are Foleys for urine, but there is also FlexiSeal and some other products on the market that are basically a Foley for stool.  So if someone has a lot of diarrhea, they could get a FlexiSeal inserted in their rectum.  That will collect the stool and keep it off the patient’s skin.  There is also highly absorbent pads that wick away moisture that could be used for this patient. 

Activity/Mobility.  If it is not impaired, then just encourage activity as tolerated.  Make sure the patient gets up out of bed, ambulates as they feel able, and just provide routine skin care.  However, if the patient’s activity or mobility is impaired, you want to make sure to educate them or the nursing staff that they need to change positions frequently. They should consider a PT/OT consult, obtain a wheelchair cushion, make sure the patient weight shifts in the wheelchair, decrease the time sitting to one to two hours, consider a higher level support surface, elevate the heels off the bed, use of foam wedges for positioning, or consider use of an assistive device such as a trapeze so that they can reposition themselves in the bed as needed. 

We are going to talk briefly about nutrition.  Nutrition is a very important part of wound healing in general, and especially in pressure ulcers.  If someone has poor nutrition, they are going to be at increased risk for pressure ulcer development and then once they have pressure ulcers, they actually need a higher intake of protein to actually heal that pressure ulcer.  So it is important for everyone with pressure ulcers to have a dietician consult, and it is necessary for compromised patients to have adequate vitamins, minerals, fats, proteins, and calories to protect themselves from skin damage, and in adequate protein intake can lead to that increased risk of pressure ulcers as I mentioned, as well as delayed wound healing. 

Two indicators that they look at for nutrition are albumin and prealbumin.  They both look at protein stores, but albumin has a longer half-life.  The patient may be undernourished before you even see a change in albumin.  There are a lot of other factors that can affect an albumin such as liver disease, fluid status, kidney failure, etc.  So it is not as sensitive an indicator of malnutrition as prealbumin.  Prealbumin has a half-life of just two to three days and it gives a better picture of what the patient’s current nutritional status is, and they are not as affected by kidney or liver disease or fluid changes.  If not impaired, then just make sure that patients can reach meals without difficulty and encourage requesting assistance if needed.  If nutrition is impaired, you want to encourage meals and assist as needed, offer supplements, assess needs for oral care, and assess as needed.  Consider a dietician consult and the patient may actually require a feeding tube or other type of nutrition if they cannot adequately take in nutrients orally. 

Finally friction and shear.  Again if no apparent problem, you will provide routine skin care.  If there is a potential or current problem, then as we mentioned already, use a draw sheet to lift or turn in bed, keep the head of bed below 30 degrees, consider heel or elbow pads or socks, and consider use of an assistive device such as a trapeze. 

I have already touched on a couple of these things, but you want to consider these aspects of the history as well.  Were they found down at home on the floor?  Then they may have deep tissue injury on the side they were lying on.  Were they in the ER for a while on a nonpressure relieving stretcher?  Then they might have a pressure ulcer develop just in the ER.  It is important to collaborate with your emergency department to get better stretchers or if they think someone is at high risk and will not be transferred to an acute or medical floor for a while, they might want to arrange to have a bed brought down from one of the units for the patient to be on until a transfer is possible.  Same thing, were they are in the OR for several hours.  Many ORs, I would hope most ORs now ensure that patients are well-padded and bony prominences are offloaded during surgery, but sometimes if a patient ends up being in surgery for 13 hours, the padding is just not enough and they may have breakdown.  One thing that people might not always think about is those patients who are refusing care.  Sometimes patients refuse to be on the correct surface, they refuse to be turned, and really there is nothing you can do about that.  If they refuse, just document they refused and that you explained the benefits and risks, but the patient still chose not to follow that plan of care.

So just in summary, pressure ulcer prevention is key.  You want to get in there with earlier interventions.  Team effort is absolutely necessary involving nursing, therapy, and dietary.  Nutrition needs to be assessed.  Passive repositioning by a caregiver might be necessary.  So it should be done at least every two hours with a bed bound patient and every 15 minutes with a chair bound.  Pillow bridging should be done.  Place the pillow flat under the patient from patient shoulder to hip so that you get no more than a 30 degree angle.  I have picture of that coming up of a pressure relief or pressure reduction support surface for the chair and the bed.  Donut pillow devices are not recommended because they cause increased pressure to surrounding tissues.  Then the Prevalon or Heel-lift boots and the turn and position system can help prevent pressure ulcers as well. 

Here is an example of that 30 degree positioning (Figure 33).  Essentially it is as easy as taking a pillow and putting it from the shoulder to the hip and just gently placing it there and then rolling the patient back on it.  That will give enough of a 30 degree angle so that you are not placing the patient directly on the opposite hip causing pressure on the hip, but you are still getting pressure off of the sacrum. 

Figure 33 30 degree positioning

Figure 34 Inflatable ring cushion

This is a big no-no (Figure 34).  It is great for hemorrhoids.  It is great for maybe after a pilonidal cyst surgery.  But for pressure ulcers, it is no good.  You will get relief right here, but you are going to put a lot of pressure on all this tissue and you are going to get breakdown here.  These are some of the heel relief devices that are available (Figure 35).  This is called a Prevalon boot, and it actually suspends the heel completely.  You can see right here that there is a window for the heel and it also comes with a wedge.  So if a patient tends to externally rotate, the wedge can help keep them in a more neutral position.  This is a Heel-lift boot and then this is a heel suspension pillow (Figure 36).

Figure 35 Heel relief device

Figure 36 Heel lift boot and heel suspend pillow

Figure 37 is just showing an inappropriate use of pillow offloading.  The pillow is too far up underneath the patient’s knee so that the heels are actually digging right into the bed.  The right side shows a pillow is right underneath the heels.  Again the heels are not being offloaded.  What you want is for the pillow to come right, the edge of this pillow to be right at the ankle so that the heels are elevated off of the mattress, but then you also have to be careful that you are not putting too much pressure on the calf or the posterior ankle causing pressure ulcer there. 

Figure 37 Incorrect pillow usage for pressure relief

Figure 38 Turn and position system

A fairly new system that has come out by a company called Sage is the Turn and Position system (Figure 38).  It is used to help prevent sacral pressure ulcers.  This is actually the same company that makes these Prevalon boots, and it is the same material in the Prevalon boot that is in this Turn and Position system.  What it comes with is a low friction glide sheet and this is the low friction glide sheet.  Then it comes with absorbent pads.  Then it comes with two wedges.  This absorbent pad is a microclimate pad in that if a bed is a low air loss bed, it will allow the air to continue to circulate and keep the patient from getting too moist.  What is also nice is that it has handles on the side of the glide sheet.  Then as you see what they recommend is you put one wedge right above the sacrum and one wedge below the sacrum.  Then you would take the handles and gently glide the patient onto the wedges so that their sacrum is completely offloaded.  Benefits of this are two-fold.  It is a patient benefit because it will help prevent sacral pressure ulcers.  It helps manage moisture with that moisture microclimate body pad, and it minimizes friction and shear.  It is also found to help decrease strain on staffs’ back, shoulders, and wrists.  It requires 71% less force to turn a patient with this system, then with a standard draw sheet and pillows.  Fewer nurses and less time is needed as well.  They have actually come out with a bariatric one for patients up to 500 pounds which helps immensely in turning those patients and getting pressure relief for them. 

First we will talk about pressure mapping.  It is a tool to assess the effectiveness of cushions and support surfaces in relieving pressure.  It is also very helpful to educate patients about performing pressure relief and equal weight bearing.  If increased pressure is suspected, they will map the pressure and then they can show the patient where they are having more pressure.  It is very helpful to send this objective data to insurance companies to show that a person is at increased risk of skin breakdown if they do not have a more expensive pressure relieving cushion.  It can help demonstrate where increased pressure is located and then evaluate the sitting circumstances to see what is causing pressure in that area. 

This is what the system looks like.  This actually shows where the pressure is in sitting.  So in this diagram or in this illustration, you can see it is right over the ischial tuberosities.  Here is an example that this therapist did out in California (Figure 39) .  She had a patient who had a pressure ulcer on his coccyx.  While they did the pressure mapping in his wheelchair cushion and found he had adequate pressure relief there, he still was not having wound healing.  What they did is look at his toilet seat.  They found that when he was sitting on his toilet seat, he was getting increased pressure on this coccyx, thus causing the wound not to heal.  They turned the toilet seat around.   So now his coccyx is offloaded when he is sitting on the toilet and the pressure is actually being distributed onto his thighs, not onto his open wound. 

Figure 39 Pressure mapping on toilet seat

Pressure relief surfaces basically were calculated arbitrarily by looking at capillary closing pressures on dogs.  It was found to be 12 to 32 mmHg.  That is not true for everyone, but it is general enough that they can make surfaces that address most patients capillary closing pressure.  There are pressure reducing surfaces, pressure relieving surfaces, and then pressure redistribution. 

Pressure reducing surfaces help lower the tissue interface pressure, but do not eliminate them.  It keeps the interface pressures between 26 and 32.  This is still below capillary closing pressure.  Pressure relieving surfaces reduce it even more in any position and in most body locations.  It keeps the interface pressure less than 25 mmHg.  The better term is actually pressure redistribution because you are not actually taking any pressure away per se, you are just redistributing it to other areas so that it is not on the bony prominence.  Blagg, a physical therapist who wrote “Preventing Pressure Ulcers,” says as a general rule the softer more pliable materials provide better pressure reduction, but a decreased stability, while the firmer surfaces provide better stability.  So if you are looking to get a wheelchair cushion for a person that does not have great balance, you might want to go with a firmer surface because it will give them better stability, but you have to be more stringent in looking at their skin, because they might not get the pressure reduction that they need.

Support Surfaces: Bed and Wheelchair

What makes an ideal support surface?  You want it to reduce or relieve pressure under bony prominences.  You want it to control that pressure gradient that we talked about at the beginning of the presentation.  It needs to provide stability.  There should be no interference with weight shifting or transfers.  It should control temperature and moisture on the skin.  It should be fairly light weight, low cost, and durable.  It is important to remember that if something is low cost and therefore cheap, then it might end up costing more in the long run.  It has to be a good value. 

Some terminology that you might hear when beds are being discussed and cushions to a degree are static devices.  It does not actually move but it reduces or redistributes pressure by spreading load over a larger area.  Typically this is a foam mattress.  Dynamic devices move.  You might hear the air moving in these devices, but it does require a motor to operate it.  Low air loss is a series of connected air-filled pillows with low friction material over the surface.  Fluidized is where there is silicone-coated glass beads and incorporates both air and fluid support.  It almost feels like a water bed and that provides the best pressure relief.

Kinetic therapy counters the effects of immobility by continuous passive motion, but it is not used for pressure; it is used to improve respiratory function.  These beds can do percussion, vibration and then have the continuous lateral rotation therapy. 

It is important when patients are placed on these beds, that staff understand that the rotation is not taking the place of turning and positioning, but rather it is just working to help with pulmonary.  The staff still need to turn the patient and reposition them as normal. 

Overlays actually go over a foam or regular bed found in the hospital or the home, and then a bariatric bed is used for morbidly obese patients and can have any of the above devices mentioned on a reinforced frame. 

Another thing I just want to mention is with an air-fluidized bed, sometimes staff has a misconception that the patient is on this great bed so I do not need to turn them anymore.  That is not the case.  The support surface does not take the place of good turning and positioning. 

This first picture (Figure 40) shows the static device.  It is a foam mattress, really not doing a whole lot of pressure reduction or redistribution.  The next is a dynamic device (Figure 41).  As you can see it does have this pump at the end that gives dynamic pressure relief, and it is a mattress replacement system.  You would take the old foam mattress off and put on this dynamic device for pressure relief. 

Figure 40 Static device

Figure 41 Dynamic device

This is a low air loss mattress (Figure 42).  You can see that it is a series of air-filled bladders and it has many layers to it.  Basically there are tubes of air that run through this, and that air helps wick away any moisture that might be occurring from either incontinence or sweating, and it helps just decrease that moisture issue.  This is an air-fluidized mattress (Figure 43).  This one is by Hill-Rom.  It is called a Clinitron.  Up here is a low air loss surface and down here is the fluidized surface.  This one the head of bed can go up and down.  This is typically used for severe stage III or stage IV pressure ulcers on multiple turning surfaces  where the patients cannot reposition themselves.  One problem with this is if this cover gets a hole in it, then those silicone beads end up all over the place.  It can make the floor kind of slippery, and it also can be kind of hot.  Patients sometimes complain of it being too hot.  There is a way to lower the temperature, but you just have to monitor the patient especially if they have a fever, they may complain more of this bed being too hot because of the silicone beads and the heat used to move the beads around. 

Figure 42 Low air loss mattress

Figure 43 Air fluidized mattress

This is just two examples of kinetic beds (Figure 44).  The left is the Hill-Rom Total Care Sport, and it does percussion, vibration and turning to assist with pulmonary function, but it is not enough of a turn for pressure relief.  And then the right is a rotating bed.  It actually does 360 degree rotation to aid in pulmonary function.  It helps keep the fluid in the lungs from settling in one spot.  This is not for pressure relief, it is for respiratory function. 

Figure 44 Hill-Rom  and Rotating bed (kinetic beds)

Here is an example of an overlay (Figure 45).  This is just a static overlay, so it is just almost like a blow up mattress you might have at home.  And this one here on the right actually has a pump associated with it, and it helps redistribute the air to keep pressure off of those bony areas. 

Figure 45 Static and dynamic overlay

These are just two examples of bariatric beds (Figure 46).  They often have rotation device and handles built in to help with staff moving the patient and decreasing staff injuries.  Again a trapeze above this bed will be immensely appreciative to the staff and the patient because they can help themselves turn instead of relying on others. 

Figure 46 Bariatric beds

When do you use what type?  A static support surface typically should not be used with patients with pressure ulcers, but sometimes you cannot get approval for a more dynamic bed at home.  So as long as the patient can assume a variety of positions without bearing weight on the pressure ulcer, they should be okay on the static device.  The dynamic device is indicated for patients who cannot assume a variety of positions without bearing weight on the pressure ulcer, or if they fully compress a static support surface or if there is documentation that the pressure ulcer is not healing with their current bed.  Finally low air loss or fluidized air mattresses or surfaces should be used for large stage III or IV pressure ulcers on multiple turning surfaces, meaning patients have a stage III or IV sacral wound, a stage III or IV right hip wound, a stage III or IV left hip wound.  They really have no surface to be turned on that does not have a pressure ulcer.  That is when these beds are indicated.  Also they are good for when patients have excessive moisture on their skin because again it will help dry out the skin and prevent pressure ulcers or moisture damage. 

As we mentioned the seated patient needs to be thought of as well because pressure ulcers can occur in sitting.  So when patients are in wheelchairs, specialized cushions should be used.  There are many different options available.  You must be really careful that the patient does not bottom out on the surface, and that the surface received regular maintenance.  Typically insurance companies will only pay for these every five years, and they should last five years if taken care of.  If they are maintain proper inflation, if they  get them checked out frequently, then they should be able to last five years.  Also you want to consider the patient’s posture when deciding on the proper cushion because the same cushion will not work for everyone.  When you are considering the seated patient, you must look at what that pressure ulcer, if they get one, will do to a wheelchair bound patient, especially young active patients that are living with spinal cord injuries.  This was a quote from that therapist that did the pressure mapping in California.  She said, “Dressing changes, close monitoring of skin, limited sitting time, and restrictions of normal activities including lost time from work disrupt their daily life for days, weeks, or even months.  Complications such as wound infections can occur which increase healing time and can lead to other medical issues.  Dealing with a pressure ulcer can be discouraging, even depressing, especially if you worked very hard to take good care of your skin.”  So these young patients with spinal cord injuries, they are trying to get back to having as normal a life as they possibly can, and then to develop a pressure ulcer and all the sequelae that come along with a pressure ulcer can really cause discouraging complications as this mentioned, and it can really make it difficult to deal with these wounds. 

Wheelchair cushion and cover materials have advanced a lot in the last 20 or 30 years.  The best type is static air because it allows movement of air among the channels to redistribute pressure and to some extent shear.  But some of the downsides include a potential for over or underfilling, a potential for the seams to fatigue and leak, or an accidental puncture.  That is why proper maintenance is so important.  Also there are new materials out that cover the cushions and they serve two purposes.  They protect the cushion to make it last longer, but also protects the skin from moisture.  It helps wick away moisture from the skin so they do not get moisture damage. 

Here are some examples of wheelchair cushions (Figure 47).  They may have gel in them.  They may have foam.  They may have air bladders or it might be a combination.  Common cushion manufacturers include RoHo, Jay, you may have heard of the Isch-Dish.  These are all common wheelchair cushions to help prevent pressure ulcers. 

Figure 47 W/C cushion examples

This is just an example of as I had mentioned that the same cushion does not work for everyone (Figure 48).  When this person, he is a little shorter, a little wider, so his wheelchair cushion works great.  He is getting adequate pressure redistribution and no real pressure damage occurring.  But in this guy, he is taller, he is thinner, he probably does not have as much subcutaneous tissue, he is getting more pressure and more skin damage occurring at the ischial tuberosities.  But they are on the same cushion.  It is just important that the same cushion does not work for everyone. 

Figure 48 Same cushion, different person

It is important when looking at support surfaces that you consider the guidelines for reimbursement.  These support surfaces are very expensive.  Wheelchair cushions are very expensive.  You want to make sure that you have all your ducks in a row so to speak to get these support surfaces approved.  Medicare has very strict guidelines for reimbursement of support surfaces and there needs to be a written order by the physician, as well as a comprehensive plan of care to get these reimbursed.  Medicare has grouped them into three groups: Group 1, Group 2, and then Group 3.  Group I is just an alternating air pressure mattress and overlay, a gel mattress or water pressure mattress. These are more basic.  Group 2 is a low air loss mattress.  It is indicated for multiple stage II pressure ulcers on the trunk or pelvis, and the patient has tried a Group 1 surface with deterioration or no improvement, or they have multiple stage III pressure ulcers on the trunk, or they have had a recent flap or skin graft.  Then Group 3 is the air-fluidized.  This is indicated for stage III or IV pressure ulcers.  If the patient is bed or chair bound, if they would require institutionalization whether in a hospital or a rehab without the bed, or they failed conservative treatment.  Those are very strict guidelines and you can get these support surfaces approved by Medicare, but you need to follow the guidelines.  

Documentation of Pressure Ulcers

A.S.S.E.S.S.M.E.N.T.(Figure 49)  These are things to note when evaluating a pressure ulcer.  The anatomical location, size and stage, whether there is sepsis or infection, exudate type and amount, erythema, surrounding skin color, swelling, saturation of dressings, sinus tract, maceration, the edges or the epithelization, is there any odor, is there any necrotic tissue or what type, are there any new blood vessels occurring, is the area tender to touch, is there any tension or induration, is there tautness, and what does the tissue bed look like?  The mnemonic is ASSESSMENT.  That just helps you remember things to look at when you are assessing a pressure ulcer.

Figure 49.  Items to document with pressure ulcers

This applies for all wounds, but real quick, to measure a pressure ulcer you are always going to document length first.  So length and width is in centimeters.  So the length is from 12 to 6 on the clock, width is from 3 to 9, and you will also want to measure the greatest length and greatest width or depending upon what your facility says you measure.  It does not matter how you measure, whether you do 12 to 6/3 to 9 method or you do greatest length/greatest width method, but you want to make sure that all your colleagues are on the same page about how you measure.  Then taking length and width you can determine the area.  This is only an approximation because most wounds are not perfectly square.  They are usually oval or round.  This area is just an approximation.  To measure wound depth, the depth is the distance from the visible skin surface to the wound bed.  You would use a cotton tip applicator and you can either do it at the center of the wound or the deepest point of the wound, or using the clock method, take depths at 12 o’clock, 3 o’clock, 6 o’clock, and 9 o’clock.  A way to see if a wound is improving is if the depth is improving.  A partial thickness or a stage II would have a depth of less than 0.2, anything greater would be a full thickness or a stage II/IV.  This is just showing how depth is measured (Figure 50). 

Figure 50 Depth of ulcer

Tunneling is a linear erosion extending from a wound.  This is also known as a sinus tract.  This is usually where there is erosion of subcutaneous tissue from an abscess.  Undermining is a tunneling or a pocket under the edges of the wound.  It is almost like a cliff, and it is caused by necrosis of tissue that is more susceptible to hypoxia than skin is.  So remember I mentioned earlier that muscle and subcutaneous tissue is more susceptible, more metabolically active than skin.  It is going to break down before the skin does sometimes.  There are several methods to measure these.  You can gently probe the undermined area and measure the deepest point, identifying where you measured it, or you can go around using like a clock method.  Here is an example of undermining (Figure 51).  Right here(Figure 52) is the actual wound that you can see with your eyes, but then if you probed with a cotton swab, you would see that the wound actually extends farther in each direction.  So you would document undermining at 9 o’clock, 1.0 cm and undermining at 3 o’clock, 3.0 cm.  That is exactly how you would want to document it.  In a good way, if you are taking pictures is to put the cotton swab in the undermined area and then put another cotton swab right next to it, so that you can get a visual of how much undermining there actually is.  This is just another example of undermining (Figure 53).  And here the person actually took a marker and filled in where the undermining is, so that when someone else comes along or the next time they come along, they can see if that undermining improved. 

Figure 51 Measuring tunneling and undermining          

Figure 52 Measuring undermining

Figure 53 Another example of undermining.  

You can measure wound volume, but it is difficult to do, and usually only done for research purposes and they are not completely accurate.  You could do a wound volume with saline and a syringe.  You would put a set amount of saline in the syringe and inject the saline into the wound.  Then when you fill up the wound and  you see how much saline is still left in the syringe.  That gives you an idea of volume is cubic centimeters. Or you could do a mold of the wound, which is not common at all except in research purposes.  You would actually use, the way dentists make molds of teeth, you would use the same kind of thing to make a mold of the wound.  Then you could determine volume that way. 

Another way is wound tracing.  This can really help show healing better than say just measurements.   Here is an example of a wound tracing( Figure 54).  In this picture, we see where the wound actually is and then this is the tracing.  Usually, it is two layers of plastic.   You rip off the layer that actually touched the wound and you have the clean one that you can put in the chart.  The dash lines are the undermining and the actual wound is the solid line.  N stands for necrotic, so there is probably eschar or slough here.  Then F stands for full thickness.  A tool that was developed about 8 or 10 years ago is called the Visitrak.  It was developed by Smith and Nephew, a common wound care company.  I really thought that is was going to take off, but it ended up not taking off at all.  You do not see it used anywhere.  It just seemed more practical until you tried to use it, and then it was not really practical to do.  When you are busy in a wound center or hospital, trying to see a bunch of wounds, you just could not take the time to trace the wound and then take it to the Visitrak machine, and try to trace it on the machine.  It did not take off as well as I thought it would, but it is a pretty neat apparatus to use for measuring wounds.  It is reported to have 94% accuracy.  You can calculate the wound area and look at percentage of changes in size, and then you can also calculate percentage of necrotic tissue and how that changes as the wound heals.  The wound is traced using a tracing film, then you place the film on the Visitrak device and trace it onto the screen and then it will give you a digital readout of the surface area.  It is believe to be more specific than the measuring we already talked about.  Here you can see, this is a pig model ( Figure 55).  I apologize to anyone that does not like testing on animals, but this just demonstrates how they were tracing the wound on the pig and then they brought the tracing over to the Visitrak, and using the stylus on the Visitrak, they were able to trace out the size of the wound and get an actual area. 

Figure 54 Wound tracing

Figure 55 Another example of wound tracing (on a pig-left)

Treatment Options

Now we are finally going to touch on pressure ulcer treatment.  So all those things that were so very important in preventing pressure ulcers continue being important once a pressure ulcer has developed.  Nutrition is very important, pressure reduction/redistribution, offloading and turn schedules are all very important.  But there are many different treatment options available and it all depends on the appearance of the ulcer and of course on the clinician and/or physician. 

We are not going to be going into detail with dressing options at this time.  I did talk about dressing options in my previous presentation and if anyone has any questions about dressing options, I will be happy to answer them.  But for now, we are going to concentrate on some options more advanced treatments for pressure ulcers.  First and foremost, as we looked at some of these pictures, debridement is necessary.  The wound cannot heal until it is adequately debrided and has a clean wound base.  How do you decide what type of debridement to use?  It depends on how quick you want to debride, how much pain the patient can tolerate, are they on a blood thinner, do they have a coagulopathy, and the overall health of the patient.  The different types of debridement include mechanical, sharp, enzymatic, surgical and autolytic. 

Mechanical debridement is the use of some outside force to remove necrotic tissue.  This can be a wet to dry dressing; it can be pulse lavage or whirlpool.  The advantage is they are familiar to most healthcare practitioners.  They do decrease the bacterial burden in the wound.  They can decrease the chance of infection.  However common belief now is there are more disadvantages to mechanical debridement than advantages.  They tend to be nonselective.  Wet to dry is not always used appropriately.  They can be painful on removal and can be more costly overall because you have to have more labor and more supplies.  It can actually delay normal healing time.  You can get maceration of the surrounding tissue and with whirlpools especially, if they are not adequately cleaned, you might have cross-contamination between patients.  That being said, there is a place and a time for some of these.  However, they can be more detrimental than helpful.  They are typically used on wounds with large amounts of necrotic tissue in an attempt to loosen necrotic tissue and make it easier for sharp debridement to be performed. 

Sharp debridement can be performed as a one-time procedure or can be on-going with more necrotic tissue being debrided every time.  The new recommendation is that sharp debridement be an ongoing process to keep the wound clean of microscopic debris.  Sometimes wounds get what is called biofilm on it.  They likened it almost to plaque that you get on your teeth, but it is a biofilm that is in the wound.  If that biofilm is in there and contains certain cells that are delaying wound healing, it is detrimental.  So that sharp debridement in an ongoing process will help get rid of that biofilm.  Sharp debridement can also convert a chronic wound to an acute wound.  So if a wound has stalled in its healing, if you go in and do a really good sharp debridement you can actually jumpstart it back into that inflammatory acute phase and it will start the healing.  Sharp debridement is the use of scalpels, forceps, scissors or curettes to remove nonviable tissue.  Depending on state practice acts, PTs and nurses can perform sharp debridement.  In New Jersey where I live, nurses cannot perform sharp debridement, but PTs can.  You really have to look at your state practice act.  The APTA recommends that physical therapy assistants should not perform sharp debridement as it entails constant reassessment.  However the APTA has left it up to individual states to make their own determinations.  So again, know your practice act and know whether or not your PTAs can do sharp debridement. 

Some advantages of sharp debridement are it is selective, quick and effective.  You can use it with other types of debridement techniques.  It is less invasive and can be done at bedside.  If they come into the wound center, it can be done right then and there.  A disadvantage is that it does require a level of skill or expertise to be done correctly and safely.  Sometimes nonphysicians will not be reimbursed depending on insurance companies.  If insurance companies are not knowledgeable about what PTs can and cannot do, then they might deny a claim saying that PTs are not allowed to debride.  That is when you need to be able to pull up your practice act and go back to that insurance company and say yes we can.  Another disadvantage is that it can be painful.  If a patient has a coagulopathy or is on a blood thinner, you want to be real careful with sharp debridement.  This is just an illustration of sharp debridement with a curette and with a scalpel. 

Enzymatic debridement is the use of an enzymatic topical agent to remove nonviable tissue.  Currently the only one on the market is Collagenase Santyl, and as the name implies, it breaks down collagen.  Basically it needs to get down to under the necrosis and at the wound base so it can emulsify that necrotic tissue.  This is very useful with patients who cannot tolerate sharp debridement.  A doctor’s order is required because it is a pharmacy product.  It must be used in a moist environment.  So if your wound is really dry, you want to use an Adaptic or some other nonadherent dressing to keep the wound moist.  It is best used on large wounds with more than 50% necrosis.  It is selective in that it only works on nonviable tissue and it can be used in conjunction with other debridement options.  However a problem is that it is slower and inflammation can sometimes occur on the surrounding skin because of pH changes. 

Surgical debridement is much the same as sharp, but is performed by a surgeon.  Our goal as PTs is to debride only necrotic nonviable tissue, and leave viable tissue intact.  However surgical debridement may involve going into viable tissue to produce a healthy bleeding wound edge.  That is really where the true difference is between what we do and what surgeons do.  We try to stay in the nonviable area, and they often go into viable tissue to get a healthier base. 

Finally autolytic debridement is the use of the body’s own mechanisms to debride the wound.  Basically it is encouraging moist wound healing to allow macrophages and phagocytes to clean up the wound and maintain that moist wound environment with the use of occlusive or semi-occlusive dressings.  However if the wound is infected, you do not want to use it, because infection will proliferate under that occlusive dressing. 

One of the most common treatments for pressure ulcers, once they are healthy and have been freshly debrided, is negative pressure wound therapy.  This is a system that uses special open cell polyurethane foam that you cut to the size of the wound.  Then the foam is placed in the wound and you cover it with a sticky film.  A tube is placed over the foam and you attach it to a pump which generates negative pressure.  Then drainage is collected in a canister.  One company’s unit is called the VAC.  This is the VAC pump and canister (Figure 56).  This canister goes into the pump.  This foam goes in the wound.  You cover it with this film or drape, and then you put this track pad over top.  Then you connect the two ends of the tubing and then it pulls down the foam and helps draw out the fluid. There are three basic types of foam.  Black foam has large pores and is more effective for stimulating granulation tissue and wound contraction.  White foam is denser and has smaller pores, and you would use it when you do not want granulation tissue to grow as fast or if the patient has too much pain with the black foam.  Then there is silver foam.  This is similar to black foam, but it has silver embedded into it, and that helps with any infection that might be in the wound.  

Figure 56 VAC machine and canister, foam and track pad.  

Here is an example of the black foam, the white foam, and then the silver foam (Figure 57-59)

Figure 57 Black foam

Figure 58 White foam

Figure 59 Silver foam

The rationale behind negative pressure wound therapy is that negative pressure distorts and stretches cells.  It causes mitosis and granulation tissue formation, stimulating growth of new blood vessels as well.   By removing the wound fluid in the interstitial space, it helps decrease the bacterial count and also removing that fluid helps with decreasing edema and pressure on the adjacent tissues.  It is indicated for stage III and IV pressure ulcers, split thickness skin grafts, muscle flaps, and for those that are nonsurgical candidates. 

Contraindication is if there is any eschar or necrotic tissue, it must be less than 25% necrotic to use the VAC.  You do not want to use it over untreated osteomyelitis because it could proliferate that infection.  Then you want to be careful in patients with active bleeding or who have difficulty maintaining wound hemostasis, or if they are on anticoagulants because it might actually cause more bleeding and could potentially get a lot of blood in the canister.   Here is an example of the VAC (Figure 60) foam placed in a sacral wound and then the tubing that is coming out here and going to the machine.  What they actually recommend now is that after you put the foam in the wound, you actually bridge a piece of foam out onto their hip and then put the track pad on the hip so that you are not getting any pressure on this area from the track pad. 

Figure 60 VAC on a sacral pressure ulcer

Ultrasound can also be used.  Just like ultrasound we use for regular physical therapy modality, you can also use it in wound healing.  It acts as a stimulant to cell activity and cell migration proliferation, and helps with the synthesis and release of growth factors.  Typically we would use it for its nonthermal effects. 

Electric stimulation for tissue repair helps liquefy or soften necrotic tissue.  It will reduce pain and edema, has antibacterial effects, increases ATP generation, and improves the membrane transport.  It increases collagen synthesis and organizes a collagen matrix to improve tensile strength.  There are two techniques that you can use.  One is the external placement, and that is where you place electrodes alongside of the wound.  This is also called the bipolar technique.  As we remember from electrotherapy class, the closer together the electrodes, the more superficial the result.  So if you have a deeper wound, you would want to spread the electrodes a little farther apart.  The internal electrode placement is where you place a moist 4x4 in the wound with aluminum foil and then hook it to the estim machine with an alligator clip.  The problem with that is that you do need to use a dispersive.  Here is an example of the alligator clip and aluminum foil (Figure 61).  This is an example of the bipolar technique (Figure 62).  This is a monopolar technique with the dispersive (Figure 63).  Then here is an example(Figure 64) with a  patient that had pressure ulcers on both heels.  So on one heel, they used the bipolar technique and on the other heel, they used the monopolar technique with a dispersive up on the calf.  

Figure 61 Use of aluminum foil, electrode, and aligator clip

Figure 62-64 Slides 143-145

Going back to ultrasound, there is one modality I forgot to mention in this presentation and it is a low frequency noncontact ultrasound called MIST Therapy.  I did discuss it in my earlier presentation two weeks ago, but if you want to know more about MIST Therapy, email me later and I will happy to provide you information. 

Muscle flaps are used obviously by surgeons for many different diagnoses, not just pressure ulcers, for example breast reconstruction after cancer and mastectomy.  They are indicated for defects requiring filling of dead space, coverage of exposed vital structures, treatment of osteomyelitis, functional reconstruction of muscle loss or absence in a congenital condition, or coverage of an exposed orthopedic hardware.  The problem with muscle flaps is that it requires absolute bed rest especially if it is a muscle flap over a sacral wound for 6 to 8 weeks after surgery on an air-fluidized bed such as a Clinitron.  So a lot of times, patients are not willing to be on bed rest for that long, so they might be reluctant to get a muscle flap.  Any friction, shear, or pressure can damage the flap and cause it to fail.  If the wound was not properly debrided and free of infection at time of placement of the flap, the flap will also fail then.  So here is an example or a diagram of a muscle flap over a sacral pressure ulcer (Figure 65).  They cut part of this gluteal muscle and skin out, and then they placed it and pulled all the skin over.  Here is an example of a muscle flap for an ischial tuberosity pressure ulcer (Figure 66). They are showing where the skin is going to be coming from and then on the right is the actual healed flap. 

Figure 65  Muscle flap over sacral ulcer

Figure 66 Another example of muscle flap over pressure ulcer

How to determine how well your facility is doing with preventing pressure ulcers?  We have talked about what pressure ulcers are.  We have talked about how to stage a pressure ulcer.  We have talked about how to prevent them with different support services and then how to treat them.  But your hospital administration will want to know how we are doing.  Are we giving our patients pressure ulcers or are we doing a pretty good job at preventing them?  A way to find this out is by doing a prevalent study.  Many facilities do it quarterly.  Our facility was recently started doing it monthly.  This done by looking at the number of patients with pressure ulcers or the prevalence of pressure ulcers, as well as looking at the number of patients with facility acquired pressure ulcers or the incidence.  Typically it is a team of two nurses or a nurse and an aide, and the whole hospital needs to be surveyed on the same day.  You survey all patients in the hospital, not just those at risk.  The problem with the prevalence study is it only gives a snapshot of that one day in time of how well you are doing, and you really cannot do anything about those patients admitted already with pressure ulcers.  So your prevalence may look high, but most of those patients came in with those pressure ulcers.  The better indicator is incidence.  This is looking at the number of patients with hospital or facility acquired pressure ulcers divided by the census of the facility.  If you want to learn a little bit more about prevalence studies, you can go to the National Database of Nursing Quality Indicators. 

Here is an example.  A 300-bed hospital, 290 patients were surveyed today.  Out of those 290 patients, 20 people had pressure ulcers.  You do not count how many pressure ulcers; you just count how many patients with pressure ulcers.  The prevalence would be 20 patients divided by 290 patients surveyed times 100 to get 6.89%.  Out of those patients, five of them acquired that pressure ulcer while they were in the hospital.  Incidence is 5, the number of patients who got the pressure ulcer in the hospital divided by the number of patients surveyed times 100 which is 1.72%.  That is actually a pretty good ratio.  Ideally facilities would like a 0% incidence and this is usually the goal for a facility, but it is not always achievable, especially depending upon the acuity and the sickness of the patients surveyed. 

Also many facilities take photos of wounds at time of admission, upon discovery of pressure ulcers, and at time of discharge to photo document that wound.  This is especially important for wounds containing a lot of necrotic tissue.  Sometimes those pressure ulcers will become bigger before they start to heal because of the debridement of the necrotic tissue.  So a good quality photograph can show changes in the quality of the wound and demonstrated complications not always seen.  Typically digital cameras are used and you want to include a ruler, the location of the wound, the patient’s name, the medical record and the date in the picture.  This just helps to prove if it ever went to court that you did not manipulate the picture at all once it was taken.  Obviously that can be easily done with PhotoShop, but if you put in the ruler with all those indicators, it is very difficult to digitally enhance or change that picture.  Wound photography can be used to prevent litigation.  Wounds should be documented with photos upon admission, as well as upon discharge.  Consent should be acquired before taking photos, but a lot of times that consent is built into the general hospital consent.  It does become a permanent part of the medical record.  Wound photography is affected by light.  Sometimes flash can give a blue tone to the wound.  Incandescent light will give a yellow tone.  You can have special film with a grid in it that will actually help measure the wounds and especially in a wound center, a series of several pictures can be used to document the improvement of the wound and they can be stored in the computer for future use. 

In conclusion, pressure ulcer prevention and treatment is truly a team effort.  It requires every member of the team to be on board from the nursing aide to nutrition to therapist to the nurse to the doctor.  All the expensive mattresses and support surfaces in the world will not prevent pressure ulcers by themselves.   One study demonstrated the prevalence of pressure ulcers was only reduced 5% in this facility with pressure reduction mattresses alone, but when it came with a combination of pressure reduction mattresses and a multifaceted education strategy reduced the incidence by 15%.  So it is imperative that staff as well as the patient and their caregivers are educated in techniques to prevent pressure ulcers.  And finally, not all pressure ulcers are preventable.  Sometimes the patient’s overall health is so poor that a pressure ulcer is just unavoidable.  However a large majority of pressure ulcers can be prevented with proper care of the patient.  Please remember that prevention is key.  If we can prevent them from happening at all, we will not have to worry about treating them.  For more information on pressure ulcers, visit the National Pressure Ulcer Advisory Panel website at

I thank you very much for your attention this afternoon and I will take any questions you may have.


Questions and Answers

Q:  How do you decide between the three heel relief devices that you described and what are their differences?

A:  A lot of times it comes down to what your facility already has.  All of them are good and even a pillow is good when used appropriately.  We have here the Prevalon system.  We like it because the outside is a like a parachute material so there is very little friction and shear.  So if the patient is moving their heel up and down in bed, it helps just glide along the sheet surface.  In my previous facility, I had the Heel Lift Boot which is more of that egg crate material, and that worked fine.  Then the Medline pillow works well too, but I think that it is more expensive.  If your facility refuses to have any of these devices, then just make sure that there are enough pillows out there in your facility that adequate pressure relief can be done with a pillow.  Because a pillow done appropriately takes off just as much pressure as one of those heel relief devices.  It is really what your facility has.  I will say that those little heel bows or you might see them in nursing homes, they are like heel protectors, they are not as good as these because they do not actually relieve the pressure.  They give a little more cushioning than the bed would, but they do not actually take pressure away.  These devices actually completely suspend the heel, where those little heel booties do not. 


Q:  In home care, I have a hard time getting mattresses approved on the first try.  Do you have any advice on this? 

A:  As I mentioned, you just really need to find out what the guidelines are and make sure that you follow them.  Just keep fighting it.  It is unfortunate because it does take time and resources to continue to fight, but if you can demonstrate that they have multiple stage III or IV ulcers, or you can demonstrate that they have been on a particular surface for a while and now their wounds are deteriorating, you should be able to get it approved.  If you cannot, just keep fighting because eventually they have to approve it because otherwise the patient is just going to get a deeper pressure ulcer and it is going cost more money for the insurance company.  So just keep fighting it.  Unfortunately some insurance companies will do anything and everything they can to not pay, and a lot of times it will take even three times to get something approved, and they will just keep denying it.  But if you keep fighting, you will eventually get there. 




jennifer a gardner

Jennifer A Gardner, PT, DPT, MHA, CWS

Dr. Gardner has been a physical therapist for 15 years with the last 10 concentrated solely on wound care. She became a Certified Wound Specialist in 2001 and recently successfully passed her re-certification in October 2011. Currently, Dr. Gardner is employed at Underwood-Memorial Hospital as the Manager of Wound Care Services, supervising both inpatient wound care and the outpatient wound center. In addition, she has been adjunct professor at College of St. Scholastica in Duluth, MN for the last 7 years, teaching Integumentary to doctoral physical therapy students.  Dr. Gardner has presented both nationally and internationally on various wound care topics and continues to participate in research studies on new concepts in wound healing.

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Course: #1726
CEUs/Hours Offered: See All State Associations
AK/2.0; AL/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; KY/2.0 Category 2; MA/2.0; MD/0.2; ME/2.0; MI/2.0; MO/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NJ/2.0; NY/2.0; OK/2.0; OR/2.0; ProCert/FSBPT/2.0; RI/2.0; SD/2.0; TX/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WY/2.0

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Wound Treatments and Dressing Options [Recorded Webinar Course]


Jennifer A Gardner, PT, DPT, MHA, CWS
Course: #1731
CEUs/Hours Offered: See All State Associations
AK/2.0; AL/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; KY/2.0 Category 2; MA/2.0; MD/0.2; ME/2.0; MI/2.0; MO/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NJ/2.0; NY/2.0; OK/2.0; OR/2.0; PA/2.0 GEN; ProCert/FSBPT/2.0; RI/2.0; SD/2.0; TX/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WY/2.0

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So, Your Patient has a Pressure Ulcer! Now What? [Recorded Webinar Course]


Jennifer A Gardner, PT, DPT, MHA, CWS
Course: #2230
CEUs/Hours Offered: See All State Associations
AK/2.0; AL/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; KY/2.0 Category 2; LA/2.0; MA/2.0; ME/2.0; MI/2.0; MO/2.0; MS/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NM/2.0; NY/2.0; OH/2.0; OR/2.0; ProCert/FSBPT/2.0; RI/2.0; SD/2.0; TX/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WV/2.0; WY/2.0

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Need CEUs? Join our CEU Total Access Program to get unlimited CEUs.

Only $99/yr

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