Pressure Ulcer

International NPUAP-EPUAP Pressure Ulcer Definition

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

Additional information: Staging a Pressure Ulcer chart

What is a Pressure Ulcer?

  • A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

What are the Risk Factors Involved?

  • Inability to perceive pressure
  • Incontinence/Moisture
  • Decreased activity level
  • Inability to reposition
  • Poor nutritional intake
  • Friction and shear

Clinical Pearls:

  • Calculate an individual’s risk assessment score using the Braden Risk Assessment Scale
  • Select an appropriate support surface (static, dynamic, low air los, or air fluidized) according to the score on the Braden Risk Assessment Scale
  • DO NOT reverse stage.  Stages define level of tissue injury, NOT progression of ulcer development or healing
  • Reposition frequently; At least every 2 hours
pressure points of the body