Pressure Sores and Bed Sores

A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.

Normal capillary refill is 16-33 mmHg.

Ischemia occurs with prolonged pressure >33 mmHg:

Ischial tuberosity: >100 mmHg during sitting
Sacral region: 40-60 mmHg in supine
Trochanteric region: 70-80 mmHg in lateral position

NPIAP Classification or Staging

Grade	Description	Management
I	Non-blanchable redness	Protective dressing
II	Partial thickness loss of skin	Moist dressing; cleanse the wound
III	Full thickness skin loss – fat visible
	– No necrotic tissue	Moist to absorbent dressing Cleanse the wound
	– Necrotic tissue	Debridement (sharp if advancing cellulitis or autolytic/enzymatic/mechanical if non-urgent) Then, moist to absorbent dressing; cleanse the wound
IV	Full thickness skin loss – bone, tendon, muscle visible
	– No necrotic tissue	Moist to absorbent dressing Cleanse the wound
	– Necrotic tissue	Debridement (sharp if advancing cellulitis or autolytic/enzymatic/mechanical if non-urgent) Then, moist to absorbent dressing; cleanse the wound

Unclassified: Depth unknown (base covered by slough/eschar) and Suspected deep tissue injury (intact discolored skin)

Use topical antibiotics for local infection.

Patients who are at risk of pressure/bed sores

Mnemonic: Pressure Sores Are Not Much Fun

Position change: restricted
Sensation: impaired
Activity: bedridden or chairbound
Nutrition: poor
Moisture: incontinence
Friction shear: difficult transfers due to contractures/spasticity

Patients meeting 3 or more of the above requires intervention for bed sore prevention.

Reference: Maffeo, R. (1998). Clinical Notebook A quick mnemonic for predicting pressure sores in ED patients. Journal of Emergency Nursing, 24(5), 418–419. doi:10.1016/s0099-1767(98)70009-1