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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #42, #63, #64, #65


Learning Objectives

  • Identify the four pathophysiologic factors of pressure ulcer development.

  • Describe the six pressure ulcer classifications according to the National Pressure Ulcer Advisory Panel’s (NPUAP’s) guidelines.

  • Outline the process for pressure ulcer risk screening and risk assessment.

  • Describe the essential strategies for a successful pressure ulcer prevention program.

  • Describe the standard of care for full-thickness pressure ulcers.

Key Clinical Points

  1. Pressure ulcers are caused by mechanical force compressing tissues between the bony skeleton and external surfaces occluding capillaries and lymphatics with resultant ischemia and buildup of metabolic cellular waste products, release of oxygen free radicals from reperfusion injury, and cellular apoptosis from cell deformation.

  2. Prevention includes screening for risk followed by risk assessment using standardized risk assessment tools to determine individual-specific risk and implementing targeted prevention interventions based on identified risk factors.

  3. Scheduled repositioning programs, use of reactive and active support surfaces, assessment and management of nutrition, and use of prophylactic dressings are key prevention strategies.

  4. Adequate, timely, and complete debridement of necrotic tissue, identification and treatment of infection and management of biofilm development, and providing a moist wound environment are the key tenets of appropriate pressure ulcer care.

  5. Medical record documentation must include pressure ulcer risk status, prevention strategies, pressure ulcer assessment (size, stage, location, and description of wound bed minimally), treatment plan and evaluation of treatment success.

  6. Partial-thickness pressure ulcers (stage 2) should heal within 60 days maximum; full-thickness pressure ulcers (stage 3/4/unstageable) should demonstrate improvement in overall ulcer status every 2 to 4 weeks.


Pressure ulcers are areas of local tissue trauma, usually developing where soft tissues are compressed between bony prominences and any external surface for prolonged time periods. A pressure ulcer is a sign of local tissue necrosis. Pressure ulcers are most commonly found over bony prominences subjected to external pressure. The most common locations are sacrum, ischial tuberosities, trochanters, and heels with sacral and heel sites most frequent. Pressure exerts the greatest force at the bony tissue interface; therefore, there may be significant muscle and subcutaneous fat tissue destruction underneath intact skin. Other terms for pressure ulcers include pressure injury, bedsore or decubitus ulcer, both of which imply development only in those confined to bed. Since the major causative factor is pressure, and because pressure ulcers occur in positions other than just lying down, pressure ulcer is the preferred term.


Pressure ulcers occur in all health care settings. Among hospitalized older patients, the prevalence of pressure ulcers in acute care units has declined by 1% to 2% over the last decade with a median estimate of 6.3%. Most (75%) present with stage 1 or stage 2 ulcers. The incidence during hospitalization ranges between 2.8% over 4 days and 9% over 5 ...

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