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

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

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