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Essentials of Diagnosis

  • Pressure ulcers are caused by pressure applied to susceptible tissues. Tissue susceptibility may be increased in the presence of maceration and by friction and shear forces.

  • Comorbid conditions, especially immobility and decreased tissue perfusion, increase the risk of pressure ulcers.

  • Most pressure ulcers develop over bony prominences, most commonly the sacrum, heels, and trochanteric areas.

  • Most pressure ulcers develop in acute hospitals; the risk is greatest in orthopedic and intensive care unit patients.

  • Pressure ulcers can be stage I (blanchable hyperemia), stage II (extension of the ulcer through the epidermis), stage III (full-thickness skin loss with damage or necrosis of subcutaneous tissue), or stage IV (full-thickness wounds with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures).

  • Pressure ulcers do not necessarily progress from stage I through stage IV.

General Principles in Older Adults


Pressure ulcers are the visible evidence of pathologic changes in the blood supply to dermal tissues. The chief cause is attributed to pressure, or force per unit area, applied to susceptible tissues. However, external pressure or shear force is increasingly viewed as a necessary but insufficient cause for pressure ulcers. In patients exposed to the same pressure load and duration of surgery, individual intrinsic factors appear to play a larger role in development of a pressure ulcer than the tissue interface pressure. Intrinsic factors leading to derangement in tissue perfusion may account for the development of a pressure ulcer, despite the provision of common prevention measures that include pressure reduction. These factors are beginning to be identified but more research is needed.

Thomas  DR. Does pressure cause pressure ulcers? An inquiry into the etiology of pressure ulcers. J Am Med Dir Assoc. 2010;11(6):397-–405.
CrossRef  [PubMed: 20627180]


Therapy for pressure ulcers is generally empiric, based on anecdotal experience, or borrowed from the treatment of patients with acute wounds. It is problematic because of multiple comorbidities, chronic duration of pressure ulcers, and, frequently, the physician's relative unfamiliarity with options.

Recognition of risk, relief of pressure, and optimizing nutritional status are components of both prevention and management guidelines. For persons with identified pressure ulcers, assessing the wound and implementing strategies for local wound care are paramount.

Thomas  DR. Issues and dilemmas in the prevention and treatment of pressure ulcers: a review. J Gerontol A Biol Sci Med Sci. 2001;56(6):M328-–M340.
CrossRef  [PubMed: 11382790]
Thomas  DR. Prevention and management of pressure ulcers. Rev Clin Gerontol. 2008;17:1-–17.
Thomas  DR. Prevention and treatment of pressure ulcers: what works? What doesn't? Cleve Clin J Med. 2001;68(8):704-–707, 710-–714, 717-–722.
CrossRef  [PubMed: 11510528]


The primary source of pressure ulcers appears to be the acute hospital. Among patients ...

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