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Medical care of older persons in residential aged care facilities (Silver Book)

Pressure ulcers

Assessment and management

A pressure ulcer (bedsore, decubitus ulcer) is an area of localised damage to the skin and underlying tissue caused by pressure, shear or friction.213 Friction and moisture are the most important factors in the development of superficial skin breakdown. Pressure and shearing forces have a greater effect on subcutaneous and muscle tissues. Ulcers can be deep, even with minimal skin breakdown, and may not be evident until days after injury.214 They commonly form over bony prominences such as the heels, the malleoli and the sacrum. Pressure ulcers significantly reduce quality of life and increase care costs, as well as the length of hospital stay.215 Prevalence in Australian aged care homes is between 3.4 and 5.4%.216

Most pressure ulcers are preventable adverse events. Many Australian hospitals and RACFs implement programs for the prevention and management of pressure ulcers. The first national guidelines were developed in 2001 by the Australian Wound Management Association.217 Guidelines are available through NICS Pressure ulcer resource guide at

The more recent Queensland Health Pressure ulcer prevention and management resource guidelines218 are available at


Risk assessment involves examination of the skin, nutritional and general medical assessment to identify risk factors, and use of a risk assessment tool.219 Major risk factors are immobility, sensory loss, impaired cognitive state, urinary and faecal incontinence, age over 65 years, male sex, European background, chronic illness, poor nutritional status, impaired oxygen delivery to tissues, raised skin temperature, skin dryness and the presence of pressure, shear or friction forces.220

The most commonly used risk assessment tools are the Norton Scale (Table 13),221 the Braden Score,222 and the Waterlow Risk Assessment.223

The Norton Scale is designed to identify the need for preventive pressure care in older hospital patients and aged care home residents. Each of the five items is scored from 1 to 4, with a maximum total score of 20. Scores of 14 or less rate the patient as 'at risk'of developing pressure sores, the lower the score, the greater the risk.224 Validity and reliability range from poor to good. The scale is more reliable when undertaken by registered nurses.225

Table 13. The Norton Scale 226

Physical condition

Mental condition




Good 4

Alert 4

Ambulant 4

Full 4

Not 4

Fair 3

Apathetic 3

Walk help 3

Slightly limited 3

Occasional 3

Poor 2

Confused 2

Chair bound 2

Very limited 2

Usually/urine 2

Very bad 1

Stupor 1

Bed 1

Immobile 1

Doubly 1

Preventive strategies to reduce risk factors can be incorporated into care plans for residents identified as'at risk'. Consider:227

  • daily inspection of all pressure points

  • protection of skin - routine inspection, moisturisers for dry skin, protect from moisture (treat incontinence), avoid harsh cleansers

  • pressure relieving interventions and devices - pressure relieving positions, turning schedules, repositioning intervals, reducing contact between bony prominences and support surfaces, lifting devices and aids, low pressure support surface for 'at risk' patients, dynamic support surface for'high risk'patients

  • optimise nutrition and hydration - adequate protein and caloric intake, zinc, vitamins.

Assessment and management

The ulcer should be assessed and documented daily, based on the depth of tissue destruction. Stages of pressure ulcer are defined as:228

Stage 1 - observable pressure related alteration(s) of intact skin whose indicators, as compared to the adjacent or opposite areas of the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain/itching). The ulcer appears as a defined area of persistent redness if skin is lightly pigmented. In darker skin tones, the ulcer may appear with persistent red, blue and purple hues

Stage 2 - partial thickness skin loss involving epidermis and/or dermis. The pressure ulcer is superficial and presents clinically as an abrasion, blister or shallow crater

Stage 3 - full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of the adjacent tissue

Stage 4 - full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (eg. tendon or joint capsule). Undermining and sinus tracts may also be associated with stage 4 pressure ulcers. Wound cultures are not indicated unless there is evidence of surrounding cellulitis or bacteremia. X-rays or bone scans may be indicated to diagnose osteomyelitis in deep nonhealing ulcers.229

The differential diagnosis for pressure ulcers includes venous stasis and arterial ulcers, cancers, traumatic ulcers, neuropathic and infective ulcers, vasculitides and other skin conditions.230 Table 14 shows wound characteristics by ulcer type for arterial, diabetic, pressure and venous ulcers.

Table 14 shows wound characteristics by ulcer type 231






Tips of toes or between toes, on pressure points of foot (eg. heel or lateral foot), or in areas of trauma

Plantar surface of foot, especially over metatarsal heads, toes, and heel

Over bony prominences (eg. trochanter, coccyx, ankle)

Gaiter area, particularly medial malleolus

Size and shape

Small craters with well defined borders

Even wound margins with callus

Variable length, width, depth depending on stage (see staging system)

Edges may be irregular with depth limited to dermis or shallow subcutaneous tissue

Wound bed

Pale or necrotic

Granular tissue unless PAD present

Varies from brighter red, shallow crater to deeper crater with slough and necrotice tissue; tunnelling and undermining

Ruddy red, yellow slough may be present ; undermining or tunnelling common


Minimal amount due to poor blood flow

Variable amount; serous unless infection present

Prulent, becoming serous as healing progressous; foul odour with infection

Copious, serous unless infection present

Surrounding skin

Halo of erythema or slight fluctuance indicitive of infection


May be distinct, diffuse, rolled under; erythema, oedema, induration if infected

May appear macerated, cruster, or scaling


Cramping or constant deep aching

None, because of neuropathy

Painful, unless sensory function impaired

Variable, may be severe, aching, or bursing in character

Treatment principles are to relieve pressure, promote ulcer healing, reduce risk factors and optimise general health. Pressure ulcers should heal or show signs of healing within 2-4 weeks. Provide adequate pain control, treat cellulitis, alleviate pressure and minimise oedema. Wound cleansing, product selection, and debridement of nonviable tissue (eschar, slough) depend on the stage of the ulcer. Numerous dressing protocols are available (see guidelines for details):232

  • Stage 1 - protect and cover with transparent films, barrier creams, skin sealants

  • Stage 2 - hydrate, insulate and absorb consider transparent films, occlusive wafers, hydrogels, foams

  • Stage 3 - cleanse, prevent infection and promote granulation consider calcium alginate, hypertonic saline, cavity foams, silver dressings, vacuum assisted closure

  • Stage 4 - as for stage 3 plus pack dead space.

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