iWOC Nursing Foundation Transforming Healthcare, One Person At A Time.

Pressure Ulcers

Pressure Ulcers, also known as decubitus ulcers or bed sores, occur in people with conditions that limit or inhibit movement of body parts that are commonly subjected to pressure, such as the sacrum and heels. A pressure ulcer is an area of skin that deteriorates when the skin is exposed to prolonged pressure.  This prolonged and unrelieved pressure restricts blood flow into the area and tissue damage or tissue death results.


Patients confined to wheelchair or bed are most at risk.  However, several other conditions may increase the risk of pressure ulcer development.  They are listed below.

  • People of advanced age (elderly)

  • People with mental or physical deficits that affect their ability to move

  • People with chronic conditions that prevent areas of the body from receiving proper blood flow

  • People with fragile skin, such as those taking steroids

  • People with urinary or fecal incontinence

  • People who are malnourished


A pressure ulcer generally starts as reddened area on the skin.  If the contributing pressure is unrelieved, further tissue damage will occur.  This deterioration may occur rapidly as the ulcer progresses to a blister, then an open sore, and finally a deep crater.

The most common places for pressure ulcers to form are over bones close to the skin.  These areas include the sacrum, heels, elbows, hips, ankles, shoulders, back, and back of the head.

Pressure sores are categorized according to severity.  The categories include Stage I (earliest signs) to Stage IV (worst).  Two additional stages suggest the inability to determine the severity of the wound and allow for staging to occur as the severity of the wound is revealed.  They are Unstageable and Suspected Deep Tissue Injury.

Stage I:

A stage I pressure ulcer has no break in the skin but a reddened area can be observed that does not blanch.  To assess blanching, press the reddened area.  If the area does not turn white when pressed, then it does not blanch.  The absence of blanching signifies that damage to the tissue has occurred.

Stage II:

A stage II pressure ulcer is partial thickness and presents as a clear fluid-filled blister or a shallow open ulcer over an area previously exposed to pressure.  The wound must be pink or red.

Stage III:

A stage III pressure ulcer is full thickness and develops when prolonged pressure causes damage to the tissue below the skin called the subcutaneous tissue or fat layers.  It often presents as a crater.

Stage IV:

A stage IV pressure ulcer results from damage to the muscle, bone, and sometimes the tendons and joints.  These ulcers present as deep craters.  Necrotic (dead) tissue may be present and the wound may extend beyond those areas visible in the wound bed.  If the bone is exposed, the risk of a bone infection called osteomyelitis increases astronomically.


Unstageable pressure ulcers are full thickness ulcers that are covered with significant amounts of necrotic or dead tissue.  The necrosis obscures the wound cannot be determined.  Necrotic tissue, which includes slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) must be removed before the severity of the ulcer can be determined.

Of note, dry, adherent, and intact eschar without redness or fluctuance (sponginess) on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Suspected Deep Tissue Injury:

A Suspected Deep Tissue Injury pressure ulcer presents as a purple or maroon area of discolored intact skin or blood-filled blister.  It evolves as a result of the damage of underlying soft tissue from prolonged pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Of note, Suspected Deep Tissue Injury pressure ulcers evolve.  This evolution may include a thin blister over a dark wound bed, formation of a thin eschar, or deterioration that rapidly exposes additional layers of tissue even with optimal treatment.

Care Basics

Early intervention is an essential component of the wound healing process.  Once a pressure ulcer develops, the following steps must be taken right away.

  • Remove the source of pressure.  Adequate pressure redistribution requires that the affected area float above the bed or chair surface or contributing device. Changes in position should occur at least every two (2) hours. Pillows or commercially-created foam positioners and padding can assist in repositioning the patient.

  • Take care to minimize further injury or friction to the area.  There are many commercially-made for this purpose.  However, a sheet placed under the patient can be used to prevent friction and shear during bed and chair mobility.

  • Do not massage the area of the ulcer. Massage can damage tissue under the skin.

  • Ensure adequate nutrition, hydration, and management of contributing medical conditions such as diabetes or vascular disease.  Take care to ensure that the person with a pressure ulcer eat balanced meals, drink 8 to 10 cups of water or non-carbonated low calorie fluids per day.

  • Do not use donut or ring-shaped cushions as they interfere with blood flow to that area which can cause additional tissue damage or tissue death.

  • Keep the skin clean and dry.  Provide prompt removal of urine or feces from the skin.  Use ph-balanced skin cleansers and non-abrasive cloths for all incontinence care.  Apply a moisture barrier cream routinely and following all incontinent episodes


Treat of a pressure ulcer is based on the stage and severity of the ulcer.  Discuss any new or changing pressure ulcer with your doctor.  A Certified Wound Care Nurse can assist your physician with identifying an appropriate plan of care for your wound.

Contact your physician immediately if there are any signs of an infection. An infection can spread to the rest of the body and cause serious problems. Signs of an infected ulcer include:

  • Redness, tenderness, warmth, or selling around the ulcer

  • A foul odor or pus from the ulcer

  • Fever, weakness, and confusion are signs that the infection may have spread to the blood or elsewhere in the body.

This information is for educational purposes, only.  It is not intended to replace the advice of a doctor. The iWOC Foundation disclaims any liability for any decisions made based on this information.