Pressure Ulcers

Pressure ulcers (also called pressure sores, bedsores or decubitus ulcers) are caused by pressure and time. When someone is immobile, pressure applied over time stops blood flow, usually at a pressure point. The result is skin damage or skin death. In a nursing home, 42 CFR § 483.25(b) provides that “Based on the comprehensive assessment of a resident, the facility must ensure that – (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.”

Most medical sources indicate that skin damage can result when blood flow is cut off for more than 2 to 3 hours. For that reason, immobile hospital patients or nursing home residents should be repositioned every 2 hours. Also, skin integrity should be checked regularly when changing a resident or patient’s clothing and when bathing or showering. Nutrition plays a major role in prevention and healing. GuidelineCentral indicates that “risk factors for developing pressure ulcers such as comorbid conditions, drugs that may affect ulcer healing, history of pressure ulcers, impaired or decreased mobility and others using risk assessment instruments.” Risk factors listed in F 686 of Appendix PP (State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities) include, but are not limited to:

Impaired/decreased mobility and decreased functional ability;
Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes
mellitus;
Drugs such as steroids that may affect healing;
Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or
lower extremity arterial insufficiency;
Resident refusal of some aspects of care and treatment;
Cognitive impairment;
Exposure of skin to urinary and fecal incontinence;
Under nutrition, malnutrition, and hydration deficits; and
The presence of a previously healed PU/PI. The history of any healed PU/PI, its origin,
treatment, its stages [if known] is important assessment information, since areas of
healed Stage 3 or 4 PU/PIs are more likely to have recurrent breakdown.

Appendix PP describes the staging of pressure ulcers as follows:

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below).

Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).

Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI.

Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI.

Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident’s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur.