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:

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

NPIAP Classification or Staging

bed sore staging
GradeDescriptionManagement
INon-blanchable rednessProtective dressing
IIPartial thickness loss of skinMoist dressing; cleanse the wound
IIIFull thickness skin loss – fat visible
– No necrotic tissueMoist to absorbent dressing
Cleanse the wound
– Necrotic tissueDebridement (sharp if advancing cellulitis or autolytic/enzymatic/mechanical if non-urgent)
Then, moist to absorbent dressing; cleanse the wound
IVFull thickness skin loss – bone, tendon, muscle visible
– No necrotic tissueMoist to absorbent dressing
Cleanse the wound
– Necrotic tissueDebridement (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

  1. Position change: restricted
  2. Sensation: impaired
  3. Activity: bedridden or chairbound
  4. Nutrition: poor
  5. Moisture: incontinence
  6. 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

Pressure/Bed sore Prevention

Mnemonic: NO ULCERS

  1. Nutrition and fluid status
  2. Observation of skin
  3. Up and walking or assist with position changes
  4. Lift, don’t drag
  5. Clean skin and continence area
  6. Elevate heels
  7. Risk assessment
  8. Support surfaces


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