Chapter 12. Pressure Ulcers: A Patient Safety Issue 

Courtney H. Lyder, Elizabeth A. Ayello 

Background 

Pressure ulcers remain a major health problem affecting approximately 3 million adults.1 In 

1993, pressure ulcers were noted in 280,000 hospital stays, and 11 years later the number of ulcers 

was 455,000.2 The Healthcare Cost and Utilization Project (HCUP) report found from 1993 to 

2003 a 63 percent increase in pressure ulcers, but the total number of hospitalizations during this 

time period increased by only 11 percent. Pressure ulcers are costly, with an average charge per 

stay of $37,800.2 In the fourth annual HealthGrades Patient Safety in American Hospitals Study, 

which reviewed records from about 5,000 hospitals from 2003 to 2005, pressure ulcers had one of 

the highest occurrence rates, along with failure to rescue and postoperative respiratory failure.3

Given the aging population, increasingly fragmented care, and nursing shortage, the incidence of 

pressure ulcers will most likely continue to rise. 

Preventing pressure ulcers has been a nursing concern for many years. In fact, Florence 

Nightingale in 1859 wrote, “If he has a bedsore, it’s generally not the fault of the disease, but of the 

nursing”4 (p. 8). Others view pressure ulcers as a “visible mark of caregiver sin”5 (p. 726) 

associated with poor or nonexistent nursing care.6 Many clinicians believe that pressure ulcer 

development is not simply the fault of the nursing care, but rather a failure of the entire heath care 

system7—hence, a breakdown in the cooperation and skill of the entire health care team (nurses, 

physicians, physical therapists, dietitians, etc.). 

Although the prevention of pressure ulcers is a multidisciplinary responsibility, nurses play a 

major role. In 1992, the U.S. Agency for Healthcare Research and Quality (AHRQ, formerly the 

Agency for Health Care Policy and Research) published clinical practice guidelines on preventing 

pressure ulcers.8

 Much of the evidence on preventing pressure ulcers was based on Level 3 

evidence, expert opinion, and panel consensus, yet it served as a foundation for providing care. 

Although the AHRQ document was published 15 years ago, it still serves as the foundation for 

providing preventive pressure ulcer care and a model for other pressure ulcer guidelines developed 

afterward. Nurses are encouraged to review these comprehensive guidelines. The document 

identifies specific processes (e.g., risk assessment, skin care, mechanical loading, patient and staff 

education, etc.) that, when implemented, could reduce pressure ulcer development, and the 

literature suggests that following these specific processes of pressure ulcer care will reduce the 

incidence of ulcers. Research also suggests that when the health care providers are functioning as 

a team, the incidence rates of pressure ulcers can decrease.9

 Thus, pressure ulcers and their 

prevention should be considered a patient safety goal. 

Incidence, Mortality, and Costs 

The incidence rates of pressure ulcers vary greatly with the health care settings. The National 

Pressure Ulcer Advisory Panel (NPUAP) says the incidence ranges from 0.4 percent to 38 percent 

in hospitals, from 2.2 percent to 23.9 percent in skilled nursing facilities, and from 0 percent to 17 

percent for home health agencies.10 There is ample evidence that the majority of pressure ulcers 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

occur relatively early in the admissions process. For patients in the hospital, they can occur within 

the first 2 weeks.11 With the increased acuity of elderly patients admitted and decreased lengths of 

stay in hospital, new data suggest that 15 percent of elderly patients will develop pressure ulcers 

within the first week of hospitalization.12 For those elderly residents admitted to long-term care, 

pressure ulcers are most likely to develop within the first 4 weeks of admission.13 

Mortality is also associated with pressure ulcers. Several studies noted mortality rates as high 

as 60 percent for older persons with pressure ulcers within 1 year of hospital discharge.14, 15 Most 

often, pressure ulcers do not cause death; rather the pressure ulcer develops after a sequential 

decline in health status. Thus, the development of pressure ulcers can be a predictor of mortality. 

Studies further suggested that the development of skin breakdown postsurgery can lead elders to 

have major functional impairment post surgical procedure. 

The cost to treat pressure ulcers can be expensive; the HCUP study reported an average cost 

of $37,800.2

 Cost data vary greatly, depending on what factors are included or excluded from the 

economic models (e.g., nursing time, support surfaces). It has been estimated that the cost of 

treating pressure ulcers is 2.5 times the cost of preventing them.16 Thus, preventing pressure ulcers 

should be the goal of all nurses. 

Etiology 

Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are 

compressed enough to impede perfusion, leading ultimately to tissue necrosis. Since 1930, we 

have understood that normal blood pressure within capillaries ranges from 20 to 40mm Hg; 32mm 

Hg is considered the average.17 Thus, keeping the external pressure less than 32 mm Hg should be 

sufficient to prevent the development of pressure ulcers. However, capillary blood pressure may 

be less than 32 mm Hg in critically ill patients due to hemodynamic instability and comorbid 

conditions; thus, even lower applied pressures may be sufficient to induce ulceration in this group 

of patients. Pressure ulcers can develop within 2 to 6 hours.18, 19 Therefore, the key to preventing 

pressure ulcers is to accurately identify at-risk individuals quickly, so that preventive measures 

may be implemented. 

Risk Factors 

More than 100 risk factors of pressure ulcers have been identified in the literature. Some 

physiological (intrinsic) and nonphysiological (extrinsic) risk factors that may place adults at risk 

for pressure ulcer development include diabetes mellitus, peripheral vascular disease, cerebral 

vascular accident, sepsis, and hypotension.20 A hypothesis exists that these physiological risk 

factors place the patients at risk due to impairment of the microcirculation system. 

Microcirculation is controlled in part by sympathetic vasoconstrictor impulses from the brain and 

secretions from localized endothelial cells. Since neural and endothelial control of blood flow is 

impaired during an illness state, the patient may be more susceptible to ischemic organ damage 

(e.g., pressure ulcers).21 

Additional risk factors that have been correlated with pressure ulcer development are age of 70 

years and older, current smoking history, dry skin, low body mass index, impaired mobility, 

altered mental status (i.e., confusion), urinary and fecal incontinence, malnutrition, physical 

restraints, malignancy, history of pressure ulcers, and white race.22–25 Although researchers have 

noted that the white race is a predictor of pressure ulcers, the small number of nonwhite patients in 

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Pressure Ulcers and Patient Safety

most pressure ulcer studies makes this finding questionable. The few studies that have included 

sufficient numbers of black people for analysis purposes have found that blacks suffer more severe 

pressure ulcers than nonblacks.26, 27 Only one nursing study found that blacks had a higher 

incidence rate of pressure ulcer than whites.28 In a study funded by AHRQ using the New York 

State Inpatient Data Set 1998–2000, Fiscella and colleagues29 found that African Americans were 

more likely to develop pressure ulcers than other races in hospitals. Moreover, a 2004 study 

investigating black/white differences in pressure ulcer incidence found that after controlling for 

eight resident characteristics and three facility characteristics, race was significantly associated 

with pressure ulcer incidence (hazard ratio comparing blacks with whites = 1.31, 95% confidence 

interval = 1.02–1.66).30 

Risk Assessment 

What tool and how often a pressure ulcer risk assessment should be done are key questions in 

preventing pressure ulcers. Due to the number of risk factors identified in the literature, nurses 

have found the use of risk assessment tools helpful adjuncts to aid in the identification of patients 

who may be at high risk. Most health care institutions that use pressure ulcer risk assessment tools 

use either the Braden Scale or Norton Scale, with the Braden scale being the most widely used in 

the United States. The Braden Scale is designed for use with adults and consists of 6 subscales: 

sensory perception, moisture, activity, mobility, nutrition, and friction and shear.31 It is based on 

the conceptual schema of linking the above clinical situations to the intensity and duration of 

pressure or tissue tolerance for pressure.32 The copyrighted tool is available at 

http://www.bradenscale.com.braden.pdf. The scores on this scale range from 6 (high risk) to 23 (low 

risk), with 18 being the cut score for onset of pressure ulcer risk. Research has shown that hospital 

nurses could accurately determine pressure ulcer risk 75.6 percent of the time after an interactive 

learning session on the Braden scale.33 Nurses were best at identifying persons at the highest and 

lowest levels of risk and had the most difficultly with patients with mild levels of risk (scores of 

15–18).34

The Norton Scale was developed in the United Kingdom and consists of five subscales: 

physical condition, mental condition, activity, mobility, and incontinence.35 The total score ranges 

from 5 (high risk) to 20 (low risk). 

The Braden Scale and Norton Scale have been shown to have good sensitivity (83 percent to 

100 percent, and 73 percent to 92 percent, respectively) and specificity (64 percent to 77 percent, 

and 61 percent to 94 percent, respectively), but have poor positive predictive value (around 40 

percent and 20 percent, respectively).36 The Norton and Braden scales show a 0.73 Kappa statistic 

agreement among at-risk patients, with the Norton Scale tending to classify patients at risk when 

the Braden scale classifies them as not at risk. The net effect of poor positive predictive value 

means that many patients who will not develop pressure ulcers may receive expensive and 

unnecessary treatment. Moreover, optimal cutoff scores have not been developed for each care 

setting (e.g., medical intensive care versus operating room). Thus, nurses still need to use their 

clinical judgment in employing preventive pressure ulcer care. A recent systematic review of risk 

assessment scales found that the Braden Scale had the optimal validation and the best 

sensitivity/specificity balance (57.1 percent/67.5 percent) when compared to the Norton Scale 

(46.8 percent/61.8 percent) and Waterlow Scale (82.4 percent/27.4 percent).37 It should be noted 

that the Waterlow skill is a pressure ulcer prediction tool used primarily in Europe. 

In recent years, several new prediction tools have been developed (FRAGMMENT Score and 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Schoonhoven Prediction Rule); however, these tools lack sufficient evidence to evaluate their 

predictive validity.38, 39 Thus, the use of a validated pressure ulcer risk assessment tool like the 

Braden Scale should be used, given the fair research-based evidence. The U.S. Centers for 

Medicare and Medicaid Services (CMS) recommends that nurses consider all risk factors 

independent of the scores obtained on any validated pressure ulcer prediction scales because all 

factors are not found on any one tool.40 

The usefulness of clinical informatics to assess and prevent pressure ulcers has been explored. 

A quality improvement study involving 91 long-term care facilities evaluated the usefulness of 

Web-based reports alerting nursing staff to a resident’s potential risk for pressure ulcers.41 Only 

one-third of long-term care facilities used the Web-based reports regularly to identify at-risk 

patients. Several key characteristics of facilities that were high users emerged: 

• Administrative level and nursing staff buy-in and support 

• Development of an actual process integrating the risk reports into ongoing quality 

improvement processes 

• Having “facility champions” to keep the effort focused and on track 

There is no agreement on how frequently risk assessment should be done. There is general 

consensus from most pressure ulcer clinical guidelines to do a risk assessment on admission, at 

discharge, and whenever the patient’s clinical condition changes. The appropriate interval for 

routine reassessment remains unclear. Studies by Bergstrom and Braden42, 43 found that in a skilled 

nursing facility, 80 percent of pressure ulcers develop within 2 weeks of admission and 96 percent 

develop within 3 weeks of admission. The Institute for Healthcare Improvement has recently 

recommended that in hospitalized patients, pressure ulcer risk assessment be done every 24 

hours44 rather than the previous suggestion of every 48 hours.45

Implementing a Prevention Plan 

Preventing pressure ulcers can be nursing intensive. The challenge is more difficult when there 

is nursing staff turnover and shortages. Studies have suggested that pressure ulcer development 

can be directly affected by the number of registered nurses and time spent at the bedside.46, 47 In 

contrast, however, one recent study suggested that there was no correlation between increasing the 

nurse-to-patient ratio and the overall incidence of pressure ulcers.48 Donaldson and colleagues49

noted that this particular study was limited by the fact that the researchers could not affirm 

compliance with ratios per shift and per unit at all times. Given that the cost of treatment has been 

estimated as 2.5 times that of prevention, implementing a pressure ulcer prevention program 

remains essential. 

A growing level of evidence suggests that pressure ulcer prevention can be effective in all 

health care settings. One study examined the efficacy of an intensive pressure ulcer prevention 

protocol to decrease the incidence of ulcers in a 77-bed long-term care facility.50 The pressure 

ulcer prevention protocol consisted of preventive interventions stratified on risk level, with 

implementation of support surfaces and turning/repositioning residents. The sample included 132 

residents (69 prior to prevention intervention and 63 after prevention intervention). The 6-month 

incidence rate of pressure ulcers prior to the intensive prevention intervention was 23 percent. For 

the 6-months after intensive prevention intervention, the pressure ulcer incidence rate was 5 

percent. This study demonstrated that significant reductions in the incidence of pressure ulcers are 

possible to achieve within a rather short period of time (6 months) when facility-specific intensive 

prevention interventions are used. A subsequent study by the same researchers was undertaken to 

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Pressure Ulcers and Patient Safety

evaluate the cost effectiveness of the pressure ulcer prevention protocol after a 3-year period. The 

implementation of a pressure ulcer prevention protocol showed mixed results. Initial reductions in 

pressure ulcer incidence were lost over time. However, clinical results of ulcer treatment improved 

and treatment costs fell during the 3 years.51 

A more recent nursing study examined the effects of implementing the SOLUTIONS program, 

which focuses pressure ulcer prevention measures on alleviating risk factors identified by the 

Braden Scale, in two long-term care facilities.52 The quasi-experimental study found that after 5 

months of implementing the SOLUTIONS program, Facility A (150 beds) experienced an 87 

percent reduction in pressure ulcer incidence (from 13.2 percent to 1.7 percent), which was highly 

significant (P = 0.02). Facility B (110 beds) experienced a corresponding 76 percent reduction 

(from 15 percent to 3.5 percent), which was also highly significant (P = 0.02). Gunningberg and 

colleagues52 investigated the incidence of pressure ulcers in 1997 and 1999 among patients with 

hip fractures and found significant reductions in incidence rates (55 percent in 1997 to 29 percent 

in 1999). The researchers attributed these reductions in pressure ulcer incidence rates to 

performing systematic risk assessment upon admission, accurately staging pressure ulcers, using 

pressure-reducing mattresses, and continuing education of staff. Thus, the use of comprehensive 

prevention programs can significantly reduce the incidence of pressure ulcers in long-term care. 

The use of quality improvement models, where systematic processes of care have been 

implemented have also been shown to reduce overall pressure ulcer incidence. In one study 

involving 29 nursing homes in three States, representatives of the 29 nursing homes attended a 

series of workshops, shared best practices, and worked with one-on-one quality improvement 

mentors over 2 years.53 This study found that six of eight prevention process measures (based on 

AHRQ prevention guidelines) significantly improved, with percentage differences between 

baseline and followup ranging from 11.6 percent to 24.5 percent. Another study using similar 

methods involving 22 nursing homes found 8 out of 12 processes of care significantly improved.7

Moreover, the study found that pressure ulcer incidence rates decreased in the nursing homes. 

Nursing homes with the greatest improvement in quality indicator scores had significantly lower 

pressure ulcer incidence rates than the facilities with the least improvement in quality indicator 

scores (P = 0.03). 

In the acute care setting, several studies have attempted to demonstrate that the 

implementation of comprehensive pressure ulcer prevention programs can decrease the incidence 

rates. However, no studies could be found that eliminated pressure ulcers. One large study 

evaluated the processes of care for hospitalized Medicare patients at risk for pressure ulcer 

development.7

 This multicenter retrospective cohort study used medical record data to identify 

2,425 patients ages 65 and older discharged from acute care hospitals following treatment for 

pneumonia, cerebral vascular disease, or congestive heart failure. Charts were evaluated for the 

presence of six recommended pressure ulcer prevention processes of care. This study found that 

at-risk patients who used pressure-reducing devices, were repositioned every 2 hours, and 

received nutritional consults were more likely to develop pressure ulcers than those patients who 

did not receive the preventive interventions. One explanation for this finding may be the amount 

of time (48 hours) before the preventive measures were implemented. Given the acuity of patients 

entering hospitals, waiting 48 hours may be too late to begin pressure ulcer prevention 

interventions. Thus, despite this one study, there is significant research to support that 

implementing comprehensive pressure ulcer prevention programs reduces the incidence of 

pressure ulcers. 

A key component of research studies that have reported reduction of pressure ulcers is how to 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

sustain the momentum over time, especially when the facility champion leaves the institution. It is 

clear from the evidence that maintaining a culture of pressure ulcer prevention in a care setting is 

an important challenge, one that requires the support of administration and the attention of 

clinicians. 

Skin Care 

Although expert opinion maintains that there is a relationship between skin care and pressure 

ulcer development, there is a paucity of research to support that. How the skin is cleansed may 

make a difference. One study found that the incidence of Stages I and II pressure ulcers could be 

reduced by educating the staff and using a body wash and skin protection products.54

The majority of skin care recommendations are based on expert opinion and consensus. 

Intuitively nurses understand that keeping the skin clean and dry will prevent irritants on the skin 

or excessive moisture that may increase frictional forces leading to skin breakdown. 

Individualized bathing schedules and use of nondrying products on the skin are also recommended. 

Moreover, by performing frequent skin assessments, nurses will be able to identify skin 

breakdown at an early stage, leading to early interventions. Although there is a lack of consensus 

as to what constitutes a minimal skin assessment, CMS recommends the following five parameters 

be included: skin temperature, color, turgor, moisture status, and integrity.40 

The search for the ideal intervention to maintain skin health continues. One study compared 

hyperoxygenated fatty acid compound versus placebo compound (triisotearin) in acute care and 

long-term care patients.55 These researchers found that using hyperoxygenated fatty acid 

significantly (p-0.006) reduced the incidence of ulcers. Pressure ulcer incidence was lower in an 

intervention group of acute care patients when topical nicotinate was applied (7.32 percent) 

compared to lotion with hexachlorophene, squalene, and allantoin in the control group (17.37 

percent).56 

There are several key recommendations to minimize the occurrence of pressure ulcers. Avoid 

using hot water, and use only mild cleansing agents that minimize irritation and dryness of the 

skin.8, 57 Avoid low humidity because it promotes scaling and dryness, which has been associated 

with pressure ulcer development.23 During skin care, avoid vigorous massage over reddened, bony 

prominences because evidence suggest that this leads to deep tissue trauma. Skin care should focus 

on minimizing exposure of moisture on the skin.58 Skin breakdown caused by friction may be 

mitigated by the use of lubricants, protective films (e.g., transparent and skin sealants), protective 

dressings (e.g., hydrocolloids), and protective padding. 

Mechanical Loading 

One of the most important preventive measures is decreasing mechanical load. If patients 

cannot adequately turn or reposition themselves, this may lead to pressure ulcer development. It is 

critical for nurses to help reduce the mechanical load for patients. This includes frequent turning 

and repositioning of patients. 

 Very little research has been published related to optimal turning schedules. The first such 

nursing study was an observational one that divided older adults into three turning treatment 

groups (every 2 to 3 hours [n = 32], every 4 hours [n = 27], or turned two to four times/day [n =

41]).59 These researchers found that older adults turned every 2 to 3 hours had fewer ulcers. This 

landmark nursing study created the gold standard of turning patients at least every 2 hours. Some 

6 
Pressure Ulcers and Patient Safety

researchers would suggest that critically ill patients should be turned more often. However, one 

survey study investigating body positioning in intensive care patients found that of 74 patients 

observed, 49.3 percent were not repositioned for more than 2 hours.60 Only 2.7 percent of patients 

had a demonstrated change in body position every 2 hours. A total of 80–90 percent of respondents 

to the survey agreed that turning every 2 hours was the accepted standard and that it prevented 

complications, but only 57 percent believed it was being achieved in their intensive care units. A 

more recent study by DeFloor and colleagues61 suggests that depending on the support surface 

used, less-frequent turning may be optimal to prevent pressure ulcers in a long-term care facility. 

Several nurse researchers investigated the effect of four different turning frequencies (every 2 

hours on a standard mattress, every 3 hours on a standard mattress, every 4 hours on a viscoelastic 

foam mattress, and every 6 hours on a viscoelastic foam mattress). The nurse researchers found 

that the incidence of early pressure ulcers (Stage I) did not differ in the four groups. However, 

patients being turned every 4 hours on a viscoelastic foam mattress developed significantly less 

severe pressure ulcers (Stage II and greater) than the three other groups. Although the results of 

this study may indicate less turning may be appropriate when using a viscoelastic foam mattress, 

additional studies are needed to examine optimal turning schedules among different populations. 

Reddy and colleagues62 have raised questions about the methodology in the Defloor and 

colleagues study, leading them to recommend that it may be too soon to abandon the every-2-hours 

turning schedule in favor of every 4 hours based on this one study. Thus, there is emerging 

research to support the continued turning of patients at least every 2 hours. 

How a patient is positioned may also make a difference. Lateral turns should not exceed 30 

degrees.63, 64 One randomized controlled trial that studied a small sample of 46 elderly patients in 

the 30-degree-tilt position and the standard 90-degree side-lying position found no significant 

difference in the development of pressure ulcers between the two groups.65 

Support Surfaces 

The use of support surfaces is an important consideration in pressure redistribution. The 

concept of pressure redistribution has been embraced by the NPUAP.66 You can never remove all 

pressure for a patient. If you reduce pressure on one body part, this will result in increased pressure 

elsewhere on the body. Hence, the goal is to obtain the best pressure redistribution possible. 

A major method of redistributing pressure is the use of support surfaces. Much research has 

been conducted on the effectiveness of the use of support surfaces in reducing the incidence of 

pressure ulcers. A comprehensive literature review by Agostini and colleagues67 found that there 

was adequate evidence that specially designed support surfaces effectively prevent the 

development of pressure ulcers. However, a major criticism of the current support surface studies 

was poor methodologic design. Agostini and colleagues noted that many studies had small sample 

sizes and unclear standardization protocols, and assessments were not blind. 

Reddy and colleagues62 have provided a systematic review of 49 randomized controlled trials 

that examined the role of support surfaces in preventing pressure ulcers. No one category of 

support surface was found to be superior to another; however, use of a support surface was more 

beneficial than a standard mattress. A prospective study evaluating the clinical effectiveness of 

three different support surfaces (two dynamic mattress replacement surfaces and one static foam 

mattress replacement) found that an equal number of patients developed pressure ulcers on each 

surface (three per surface).68 The researchers concluded no differences in the support surface 

effectiveness, yet large differences in the cost. (Dynamic mattress replacements cost 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

approximately $2,000 per mattress, compared to $240 per mattress for static foam mattress 

replacements.) Given the similar clinical effectiveness, cost should be considered in determining 

the support surface. 

Four randomized controlled trials evaluated the use of seat cushions in pressure ulcer 

prevention, and found no difference in ulcer incidence among groups except between foam and gel 

cushions.62 Despite the dearth of research that correlates seat cushions and preventing pressure 

ulcers, expert opinion supports the use of seat cushions. 

The CMS has divided support surfaces into three categories for reimbursement purposes.68

Group 1 devices are those support surfaces that are static, they do not require electricity. Static 

devices include air, foam (convoluted and solid), gel, and water overlays or mattresses. These 

devices are ideal when a patient is at low risk for pressure ulcer development. Group 2 devices are 

powered by electricity or pump and are considered dynamic in nature. These devices include 

alternating and low-air-loss mattresses. These mattresses are good for patients who are at 

moderate to high risk for pressure ulcers or have full-thickness pressure ulcers. Group 3 devices, 

also dynamic, comprises only air-fluidized beds. These beds are electric and contain 

silicone-coated beads. When air is pumped through the bed, the beads become liquid. These beds 

are used for patients at very high risk for pressure ulcers. More often they are used for patients with 

nonhealing full-thickness pressure ulcers or when there are numerous truncal full-thickness 

pressure ulcers. The NPUAP has suggested new definitions for support surfaces that move away 

from these categories and divide support surfaces into powered or nonpowered.69 Whether these 

new definitions will be embraced by CMS is yet to be determined. 

There remains a paucity of research that demonstrates significant differences in the 

effectiveness of the various classifications of support surfaces in preventing or healing pressure 

ulcers. Therefore, nurses should select a support surface based on the needs and characteristics of 

the patient and institution (e.g., ease of use, cost). It is imperative to have the pressure 

redistribution product (e.g., mattress or cushion) on the surface where the patients are spending 

most of their time, in bed or a chair. However, being on a pressure-redistributing mattress or 

cushion does not negate the need for turning or repositioning. 

Nutrition 

Controversy remains on how best to do nutritional assessment for patients at risk for 

developing pressure ulcers. The literature differs about the value of serum albumin; some literature 

reports that low levels are associated with increased risk.70 While the AHRQ pressure ulcer 

prevention guideline suggests that a serum albumin of less than 3.5 gm/dl predisposes a patient for 

increased risk of pressure ulcers, one study reveals that current dietary protein intake is a more 

independent predictor than this lab value.8, 42 In the revised Tag F-314 guidance to surveyors in 

long-term care, CMS recommends that weight loss is an important indicator.40 Evaluation of the 

patient’s ability to chew and swallow may also be warranted. 

The literature is unclear about protein-calorie malnutrition and its association with pressure 

ulcer development.70 Reddy and colleagues62 suggested that the widely held belief of a 

relationship between nutrition intake and pressure ulcer prevention was not always supported by 

randomized controlled trials. Some research supported the finding that undernourishment on 

admission to a health care facility increases a person’s likelihood of developing a pressure ulcer. 

In one prospective study, high-risk patients who were undernourished on admission to the hospital 

were twice as likely to develop pressure ulcers as adequately nourished patients (17 percent and 

8 
Pressure Ulcers and Patient Safety

9 percent, respectively).

71

 In another study, 59 percent of residents were undernourished and 7.3 

percent were severely undernourished on admission to a long-term care facility. Pressure ulcers 

occurred in 65 percent of the severely undernourished residents, while no pressure ulcers 

developed in the mild-to-moderately undernourished or well-nourished residents.

15

Reddy and colleagues62 concluded that nutritional supplementation was beneficial in only one 

of the five randomized controlled trials reviewed in their systematic analysis of interventions 

targeted at impaired nutrition for pressure ulcer prevention. Older critically ill patients who had 

two oral supplements plus the standard hospital diet had lower risk of pressure ulcers compared to 

those who received only the standard hospital diet.72 

Empirical evidence is lacking that the use of vitamin and mineral supplements (in the absence 

of deficiency) actually prevents pressure ulcers.73 Therefore, oversupplementing patients without 

protein, vitamin, or mineral deficiencies should be avoided. Before enteral or parental nutrition is 

used, a critical review of overall goals and wishes of the patient, family, and care team should be 

considered.74 Despite the lack of evidence regarding nutritional assessment and intervention, 

maintaining optimal nutrition continues to be part of best practice. 

Management of Pressure Ulcers 

When a pressure ulcer develops, nursing’s patient safety goal is to assist the health care team 

in closing the ulcer as quickly as possible. Nursing is also concerned with preventing further ulcer 

deterioration, keeping the ulcer clean and in moisture balance, preventing infections from 

developing, and keeping the patient free from pain. 

Many aspects of managing pressure ulcers are similar to prevention (mechanical loading, 

support surfaces, and nutrition). Clearly, the health care team has to address the underlying causes 

(intrinsic and extrinsic) or the pressure ulcer will not close. In 1994, AHRQ published clinical 

practice guidelines on treating pressure ulcers.75 Much of the evidence related to treating pressure 

ulcers was based on Level C evidence, requiring one or more of the following: one controlled trial, 

results of at least two case series/descriptive studies in humans, or expert opinion. Although the 

AHRQ document was published 13 years ago, it provides the foundation for treating pressure 

ulcers. The document identified specific indices (e.g., wound assessment, managing tissue load, 

ulcer care, managing bacterial colonization/infection, etc.). The following section supplements 

this document. 

Cleansing 

Once the pressure ulcer develops, the ulcer should be cleaned with a nontoxic solution. 

Cleaning the ulcer removes debris and bacteria from the ulcer bed, factors that may delay ulcer 

healing.76 No randomized control studies could be found that demonstrated the optimal frequency 

or agent for cleansing a pressure ulcer. A Cochrane review of published randomized clinical trials 

found three studies addressing cleansing of pressure ulcers, but this systematic review produced 

no good trial evidence to support any particular wound cleansing solution or technique for 

pressure ulcers.77 Therefore, this recommendation remains at the expert opinion level. Nurses 

should use cleansers that do not disrupt or cause trauma to the ulcer.78 Normal saline (0.9 percent) 

is usually recommended because it is not cytotoxic to healthy tissue.79 Although the active 

ingredients in newer wound cleansers may be noncytotoxic (surfactants), the inert carrier may be 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

cytotoxic to healthy granulation tissue.80 Thus, nurses should be cognizant of the ingredients in 

cleansing agents before using them on pressure ulcers. 

Assessment and Staging 

The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe 

that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound 

infections as well as being a good parameter for gauging of wound healing.40, 75 There are no 

universal parameters for assessing a pressure ulcer. Most experts agree that when a pressure ulcer 

develops its location, size (length, width, and depth), and color of the wound; amount and type of 

exudate (serous, sangous, pustular); odor; nature and frequency of pain if present (episodic or 

continuous); color and type of tissue/character of the wound bed, including evidence of healing 

(e.g., granulation tissue) or necrosis (slough or eschar); and description of wound edges and 

surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) should be 

assessed and documentd.75, 81 Upon identifying the ulcer characteristics, the initial stage of the 

should be completed. 

The staging system is one method of summarizing certain characteristics of pressure ulcers, 

including the extent of tissue damage. Hence, whether the nurse observes the epidermis, dermis, 

fat, muscle, bone, or joint determines the stage of pressure ulcer. Knowing the appropriate stage 

aids in determining the management of the pressure ulcer. However, staging of pressure ulcers can 

vary, because different nurses may observe different tissue types. In a survey of nurses’ wound 

care knowledge, less than 50 percent of new nurses (fewer than 20 years of nursing experience) did 

not feel confident in consistently identifying all stages of pressure ulcers, as compared to 30 

percent of the more experienced nurses (more than 20 years of nursing experience).82 Achieving 

consistency in staging will provide optimal pressure ulcer management. 

Pressure ulcer staging systems differ, depending on geographic location. The Europeans use a 

four-stage system.83 For Grade 1, nonblanchable erythema of intact skin, discoloration of the skin, 

warmth, edema, and induration or hardness may be used as indicators, particularly on individuals 

with darker skin. For Grade 2, indicators include partial thickness skin loss involving epidermis, 

dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Grade 3 

includes full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may 

extend down to, but not through, underlying fascia. Grade 4 includes extensive destruction; tissue 

necrosis; or damage to muscle, bone, or supporting structures, with or without full thickness skin 

loss. 

The most widely used staging system in the United States was developed in 1989 by the 

NPUAP.84 This staging system was modified from Shea’s original system.85 The staging system 

rates the pressure ulcer from superficial tissue damage (Stage I) to full thickness skin loss 

involving muscle or bone (Stage IV). If the pressure ulcer is covered with necrotic tissue (eschar), 

it should be noted as unstageable. In skilled nursing facilities, nurses must stage a pressure ulcer 

covered with necrotic tissue as Stage IV.86 In home care and nursing homes, nurses must stage 

pressure ulcers because staging is linked to reimbursement of medical expenses. 

In 2007, the NPUAP revised the staging system to include deep tissue injury, an ulcer often 

described as a purple or maroon localized area of discolored intact skin or blood-filled blister due 

to damage of underlying soft tissue from pressure and/or shear.87 The NPUAP also reclassified 

blisters and unstageable pressure ulcers. The NPUAP staging definitions were refined with input 

from an online evaluation of their face validity, accuracy clarity, succinctness, utility, and 

10 
Pressure Ulcers and Patient Safety

discrimination. The new staging system has six stages: suspected deep tissue injury, Stage I, Stage 

II, Stage III, Stage IV, and Unstageable. Table 1 presents the NPUAP definition, and Table 2 

illustrates the differences between the old and new pressure ulcer staging systems. 

Table 1. National Pressure Ulcer Definition 

Previous NPUAP Definition 2007 NPUAP Definition 2007 NPUAP Further 

Descriptions to Accompany 

Revised Definition 

Pressure Ulcer 

Definition 

A localized area of tissue 

necrosis that develops when 

soft tissue is compressed 

between a bony prominence 

and an external surface for a 

prolonged period of time. 

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. 

© 2007 NPUAP 

Table 2. National Pressure Ulcer Staging System 

Pressure Ulcer 

Stage 

Previous NPUAP Staging 

Definitions 

2007 NPUAP Definitions 2007 NPUAP Descriptions 

to Accompany Revised 

Definitions 

Deep Tissue 

Injury 

A pressure-related injury to 

subcutaneous tissues under 

intact skin. Initially, these 

lesions have the appearance 

of a deep bruise, and they 

may herald the subsequent 

development of a Stage III–IV 

pressure ulcer, even with 

optimal treatment. 

Purple or maroon localized 

area of discolored intact skin 

or blood-filled blister due to 

damage of underlying soft 

tissue from 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. 

• Deep tissue injury may be 

difficult to detect in 

individuals with dark skin 

tones. 

• The area may rapidly evolve 

to expose additional layers 

of tissue, even with optimal 

treatment. 

Stage I An observable 

pressure-related alteration of 

intact skin whose indicators 

as compared to an adjacent 

or opposite area on the body 

may include changes in one 

or more of the following 

parameters: skin temperature 

(warmth or coolness), tissue 

consistency (firm or boggy 

feel), sensation (pain, itching), 

and/or a defined area of 

persistent redness in lightly 

pigmented skin; in darker skin 

tones, the ulcer may appear 

with persistent red, blue, or 

purple hues. 

Intact skin with nonblanchable 

redness of a localized area, 

usually over a bony 

prominence. 

• The area may be painful, 

firm, soft, warmer, or cooler, 

as compared to adjacent 

tissue. 

• Stage I may be difficult to 

detect in individuals with 

dark skin tones. 

• May indicate at-risk persons 

(a heralding sign of risk). 

Stage II Partial thickness skin loss 

involving the epidermis and/or 

dermis. The ulcer is 

superficial and presents 

clinically as an abrasion, 

Partial thickness loss of 

dermis presenting as a 

shallow open ulcer with a red, 

pink wound bed without 

slough. May also present as 

Presents as a shiny or dry 

shallow ulcer without slough 

or bruising. This stage should 

not be used to describe skin 

tears, tape burns, perineal 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Pressure Ulcer 

Stage 

Previous NPUAP Staging 

Definitions 

2007 NPUAP Definitions 2007 NPUAP Descriptions 

to Accompany Revised 

Definitions 

blister, or shallow crater. an intact or open/ruptured 

serum-filled blister. 

dermatitis, maceration, or 

excoriation. 

Stage III 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 

adjacent tissue. 

Full thickness tissue loss. 

Subcutaneous fat may be 

visible, but bone, tendon, or 

muscle are not exposed. 

Slough may be present but 

does not obscure the depth of 

tissue loss. May include 

undermining and tunneling. 

• The depth of a Stage III 

pressure ulcer varies by 

anatomical location. The 

bridge of the nose, ear, 

occiput, and malleolus do 

not have subcutaneous 

tissue, and Stage III ulcers 

can be shallow. In contrast, 

areas of significant adiposity 

can develop extremely deep 

Stage III pressure ulcers. 

• Bone/tendon is not visible or 

directly palpable. 

Stage IV Full thickness skin loss with 

extensive destruction; tissue 

necrosis; or damage to 

muscle, bone, or supporting 

structure (such as tendon, or 

joint capsule). 

Full thickness tissue loss with 

exposed bone, tendon, or 

muscle. Slough or eschar 

may be present on some 

parts of the wound bed. Often

includes undermining and 

tunneling. 

• The depth of a Stage IV 

pressure ulcer varies by 

anatomical location. The 

bridge of the nose, ear, 

occiput, and malleolus do 

not have subcutaneous 

tissue, and these ulcers can 

be shallow. 

• Stage IV ulcers can extend 

into muscle and/or 

supporting structures (e.g., 

fascia, tendon, or joint 

capsule), making 

osteomyelitis likely to occur. 

• Exposed bone/tendon is 

visible or directly palpable. 

Unstagable Full thickness tissue loss in 

which actual depth of the 

ulcer is completely obscured 

by slough (yellow, tan, gray, 

green, or brown) and/or 

eschar (tan, brown, or black) 

in the wound bed. 

Until enough slough and/or 

eschar is removed to expose 

the base of the wound, the 

true depth, and therefore 

stage, cannot be determined. 

Stable (dry, or adherent, 

intact without erythema or 

fluctuance) eschar on the 

heels serves as the “the 

body’s natural (biological) 

cover” and should not be 

removed. 

© 2007 NPUAP 

The Stage I pressure ulcer may be more difficult to detect in darkly pigmented skin. A quality 

improvement study in several nursing homes found that by empowering the nursing assistants with 

education (skin assessment), use of pen lights to assess darker skin, mirrors, and financial reward, 

the researchers were able to reduce the Stage I pressure ulcers in residents with darkly pigmented 

skin.88 One method for delineating Stage I pressure ulcers in darkly pigmented skin may be the use 

of high-resolution ultrasound. Although ultrasound is widely used as a safe and cost-effective 

technique for noninvasive visualization of specific human anatomy, its use for skin assessment is 

just now available. Ultrasound utilizes the echoes of sound waves to create images of soft tissue 

anatomy.89 A probe transmits sound waves into the body. High-frequency ultrasound (20MHZ) 

12 
Pressure Ulcers and Patient Safety

will provide high resolution images of the skin and underlying soft tissue, and because the images 

are related to tissue density (not pigment), the clinician’s assessment ability is enhanced 

significantly. A recent study strongly suggests that clinicians should consider high-frequency 

ultrasound as an improved method for identifying and implementing good pressure ulcer 

preventive care.90 

The assessment and staging of pressure ulcers remains at the expert opinion level. 

Debridement 

The presence of necrotic devitalized tissue promotes the growth of pathologic organisms and 

prevents wounds from healing.91 Experts believe that debridement is an important step in the 

overall management of pressure ulcers. No randomized control trials could be found that 

demonstrated that one debridement technique is superior. Thus, the best method of debridement is 

determined by the goals of the patient, absence or presence of infection, pain control, amount of 

devitalized tissue present, and economic considerations for the patient and institution.92–94 There 

are five types of debridement: sharp, mechanical, autolytic, enzymatic, and biosurgery. 

Sharp debridement (use of scalpel or laser) is probably the most effective type of debridement 

because of the time involved to remove the devitalized tissue.95 Sharp debridement should always 

be considered when the patient is suspected of having cellulites or sepsis.96 Mechanical 

debridement uses a nonselective, physical method of removing necrotic tissue and debris from a 

wound using mechanical force. One common form of mechanical treatment is wet-to-dry gauze to 

adhere to the necrotic tissue, which is then removed. Upon removal of the gauze dressing, necrotic 

tissue and wound debris are also removed. The challenge with mechanical debridement is the 

possibility that healthy granulation tissue may be removed as well, along with the devitalized 

tissue, thereby delaying wound healing and causing pain. Thus, CMS suggests that this method of 

debridement be used in limited circumstances.40 

Autolytic debridement involves the use of semiocclusive (transparent film) and occlusive 

dressings (hydrocolloids, hydrogels, etc.), which creates an environment for the body’s enzymes 

to break down the necrotic tissue.97 Enzymatic debridement uses proteolytic enzymes (i.e., 

papain/urea, collagenase) to remove necrotic tissue.98 This form of debridement is considered drug 

therapy; therefore it should be signed on the medication record. Finally, biosurgery (maggot 

therapy) is another effective and relatively quick method of debridement.99 This type of 

debridement is especially effective when sharp debridement is contraindicated due to the exposure 

of bone, joint, or tendon.99 

Bacterial Burden 

Managing bacterial burden is an important consideration in pressure ulcer care. All pressure 

ulcers contain a variety of bacteria. Pressure ulcer bacterial contamination should not impair 

health.100 Of great concern is when a colony of bacteria reaches 105 or 106 organisms per gram in 

the ulcer.101 At these levels, the pressure ulcer can be considered infected. Healing can be impeded 

when wounds have high levels of bacteria. Robson and Heggers101 found in 32 pressure ulcers that 

spontaneous healing occurred only when the microbial population was controlled. 

Experts agree that swab cultures should not be used to determine wound infection.102 Rather a 

tissue biopsy should be conducted to determine the qualitative and quantitative assessment of any 

aerobic and anaerobic organisms present.103 Clinical signs that the pressure ulcer may be infected 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

include malodorous, purulent exudate; excessive draining; bleeding in the ulcer; and pain.104, 105

One study investigating the validity of clinical signs and symptoms used to identify localized 

chronic wound infections found signs associated with secondary wounds (i.e., serous exudate, 

delayed healing, discoloration of granulation tissue, friable granulation tissue, pocketing at the 

base of the wound, foul odor, and wound breakdown) were better predictors of wound infection 

than the classic signs of infection (i.e., increasing pain, erythema, edema, heat, and purulence).106

Overall, these researchers concluded that increasing pain and wound breakdown were both 

sufficient clinical indicators of infected wounds with 100 percent specificity. Thus, when these 

signs are present, the nurse should seek additional treatments for the patient. This will help to 

safeguard the patient from further ulcer complications. 

The use of oral antibiotics or topical sulfa silverdiazine has also been found to be effective in 

decreasing the bioburden in the ulcer bed.107, 108 Treatment using silver-impregnated dressings has 

been shown to be somewhat effective in decreasing bacterial bioburden load. One in vivo study 

found that silver-based dressings decreased specific bacteria (e.g., Eschericha coli, Candida 

albicans, and Staphylococcus aureas).109 However, a systematic review of the research literature 

found only three randomized controlled trials covering 847 participants. This Cochrane review 

determined that based on only three randomized controlled trials, there remains insufficient 

evidence to recommend the use of silver-containing dressings or topical agents for treatment of 

infected or contaminated chronic wounds.110 

The use of antiseptics to reduce wound contamination continues to be a controversial topic. 

The ideal agent for an infected pressure ulcer would be bactericidal to a wide range of pathogens 

and noncytotoxic to leukocytres. In vitro studies of 1 percent povidone-iodine have been found to 

be toxic to fibroblast, but a solution of 0.005% sodium hypochlorite (P = 0.001) caused no 

fibroblast toxicity and was still bactericidal to Staphylococcus aureus.111 Another common 

antiseptic with conflicting data is sodium hypochlorite (Dakins solution). Studies suggest that 

0.005 percent concentration of sodium hypochlorite to be bactericidal; however, its use can also 

cause inhibition of fibroblast and neutrophil migration necessary for pressure ulcer healing.112

Conversely, other in vitro studies suggest that 0.005 percent sodium hypochlorite did not inhibit 

fibroblasts. McKenna and colleagues examined the use of 0.005 percent sodium hypochlorite, 

0.001 percent povidone-iodine, 0.0025 percent acetic acid, and 0.003 percent hydrogen peroxide 

on various clinical isolates.111 These researchers found that sodium chlorite significantly inhibited 

(P = 0.001) the growth of all bacteria tested (Staphylococcus aureas, Escherichia coli, Group D 

enterococci, Pseudomonas aeruginosa, and Bacteroides fragilis) without inhibiting fibroblast 

activity, whereas povidone-iodine and acetic acid reduced only specific bacteria. 

Exudate Management 

The use of dressings is a major component in maintaining a moist environment. There are more 

than 300 different modern wound dressings available to manage pressure ulcers.113 Most dressings 

can be broken down into seven classifications: transparent films, foam islands, hydrocolloids, 

petroleum-based nonadherents, alginates, hydrogels, and gauze. Few randomized controlled 

studies have been conducted to evaluate the efficacy of dressings within a specific classification. 

Therefore, no one category of wound dressings (independent of gauze) may be better than another 

category. Most research evaluating the effects of dressings usually compare gauze (standard) to 

modern wound dressings (nongauze).114, 115, 116 These studies are inherently flawed because gauze 

dressings are not classified as a modern wound dressing; thus equivalent comparisons cannot be 

14 
Pressure Ulcers and Patient Safety

made. The studies usually have small sample sizes; thus inferences can be difficult to make. 

However, one study investigating wound-healing outcomes using standardized validated protocols 

found that primarily using nongauze protocols of care matched or surpassed the best previously 

published results on similar wounds using gauze-based protocols of care, including protocols 

applying gauze impregnated with growth factors or other agents. Thus, nongauze protocols of care 

should be used to accelerate pressure ulcer healing.117 

Nutrition 

The use of high-protein diets for patients with protein deficiency is essential to wound healing. 

One small study (n = 12) has suggested that 1.25 g protein/L/kg/day to 1.50 g protein/L/kg/day is 

needed to promote wound healing.118 However, Mulholland and colleagues119 suggested in a 1943 

journal article that as much as 2.0 g protein/L/kg/day is essential for wound healing. To underscore 

that increasing protein does have a positive effect on wound healing, researchers investigated 28 

malnourished patients with a total of 33 truncal pressure ulcers.120 The researchers found that 

patients who received the 24-percent protein intake had significant decrease (P = 0.02) in truncal 

pressure ulcer surface area compared to the group on 14-percent protein intake. Clearly, increasing 

protein stores for patients with pressure ulcers who are malnourished is essential; however, it is 

unclear from the literature what the optimum protein intake requirement is for patients with 

pressure ulcers. Most promising: the use of amino acids such as argine, glutamine, and cysteine 

have been noted to assist in ulcer healing.121 However, there remains a paucity of data to 

substantiate these claims; thus their use should be tempered with the overall goals of the patient. 

Pain Management 

Pressure ulcers can be painful. In particular, patients with Stage IV ulcers can experience 

significant pain.122, 123 A cross-sectional study of patients with a mix of chronic wounds found that 

wound stage was positively related to severity of pain.123 Moreover, pain catastrophizing was 

positively related to pain intensity and higher levels of affective distress and depressive symptoms. 

Hence, the goal of pain management in the patient with pressure ulcers should be to eliminate the 

cause of pain, to provide analgesia, or both. This goal was supported recently by the World Union 

of Wound Healing Societies consensus document, Principles of Best Practice: Minimizing Pain at 

Wound Dressing-Related Procedures.124 Pain at dressing-related procedures can be managed by a 

combination of accurate assessment, suitable dressing choices, skilled wound management, and 

individualized analgesic regimens. Dressing removal can potentially cause damage to delicate 

tissue in the wound and surrounding skin. Thus, clinicians should use multiple methods to address 

the pressure ulcer pain. This may include using dressing that mitigates pain during dressing 

changes, such as dressings containing soft-silicone, and administering analgesic prior to dressing 

changes. 

Monitoring Healing 

Presently, there are two instruments that are often used to measure the healing of pressure 

ulcers. The Pressure Ulcer Scale for Healing (PUSH) was developed by the NPUAP in 1997.125

The PUSH tool is copyrighted and available on NPUAP’s Web site.84 It quantifies the pressure 

ulcer with respect to surface area, exudate, and type of wound tissue. Using a Likert scale from 1 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

to 10 for length and width, a Likert scale from 1 to 3 for exudate amount, and a Likert scale from 

1 to 4 for tissue type, the nurse can determine whether a pressure ulcer is healing or nonhealing. 

Each of the three ulcer characteristics is recorded as a subscore, then the subscores are added to 

obtain the total score. A comparison of total scores measured over time provides an indication of 

the improvement or deterioration of the pressure ulcer. 

Few studies have been published that measure the validity and reliability of the PUSH tool. A 

study investigating the PUSH tool’s content validity found that it had both content validity (P =

0.01) and correlational validity (P = 0.05) to monitor the changing pressure ulcer status.126

Moreover, a recent prospective study by Gardner and colleagues106 of 32 pressure ulcers found 

that 21 ulcers (66 percent) healed during the 6-month study period, and 11 (34 percent) did not heal. 

The PUSH scores decreased significantly (P = 0.001) over time among the healed ulcers but did 

not among the unhealed ulcers. Thus, the PUSH tool was shown to be a valid instrument for 

measuring healing in a clinical setting. 

The Bates-Jensen Wound Assessment Tool (BWAT; formerly the Pressure Sore Status Tool, 

PSST) was developed in 1992 and is also widely used.127 The BWAT consists of 15 items. The 

first 2 items are related to location and shape of the ulcer. The remaining 13 items are scored on the 

basis of descriptors of each item and ranked on a modified Likert scale (1 being the healthiest 

attribute of the characteristic and 5 being the least healthy attribute of the characteristic). The 13 

BWAT characteristics that are scored are size, depth, edges, undermining, necrotic tissue type, 

necrotic tissue amount, exudate type, exudate amount, skin color surrounding wound, peripheral 

tissue edema, peripheral tissue induration, granulation tissue, and epithelialization. The 13 item 

scores are summed to provide a numerical indicator of wound health or degeneration. 

There is a paucity of validation studies for the BWAT. However, content validity has been 

established by a panel of 20 experts. Interrater reliability was established by the use of two wound, 

ostomy, and continence nurses who independently rated 20 pressure ulcers on 10 patients. 

Interrrater reliability was established at r = 0.91 for first observation and r = 0.92 for the second 

observation (P = 0.001).128 A recent study examined wound-healing outcomes with standardized 

assessments using the BWAT. Most of the 767 wounds selected to receive the standardized 

protocols of care were Stage III–IV pressure ulcers (n = 373; mean healing time 62 days). Partial 

thickness wounds healed faster than same-etiology full thickness wounds.117 This finding further 

adds to the validation of the BWAT tool for measuring wound healing. 

Adjunctive Therapies 

The use of adjunctive therapies is the fastest growing area in pressure ulcer management. 

Adjunctive therapies include electrical stimulation, hyperbaric oxygen, growth factors and skin 

equivalents, and negative pressure wound therapy. Except for electrical stimulation, there is a 

paucity of published research to substantiate the effectiveness of adjunctive therapies in healing 

pressure ulcers. 

Electrical stimulation is the use of electrical current to stimulate a number of cellular processes 

important to pressure ulcer healing.129 These processes include increasing the fibroblasts, 

neutrophil macrophage collagen, DNA synthesis, and increasing the number of receptor sites for 

specific growth factors.129 Eight randomized controlled studies were found in the literature. 

Electrical stimulation appears to be most effective on healing recalcitrant Stages III and IV 

pressure ulcers.130 A meta-analysis of 15 studies evaluating the effects of electrical stimulation on 

the healing of chronic ulcers found that the rate of healing per week was 22 percent for the 

16 
Pressure Ulcers and Patient Safety

electrical stimulation group compared to 9 percent for the control group.131 Thus, electrical 

stimulation should be considered for nonhealing pressure ulcers. 

Negative pressure wound therapy is widely used, although few randomized controlled trials 

have been published. This therapy promotes wound healing by applying controlled localized, 

negative pressure to the wound bed.132–134 In one prospective study investigating nonhealing 

pressure ulcers, 24 patients were randomized into two groups (wet-to-moist dressings or 

vacuum-assisted closure).133 Those patients receiving negative pressure wound therapy had a 

66-percent reduction in wound depth (P = 0.0001), compared to the wet-to-moist dressings group, 

which had a 20-percent wound depth reduction.133 Much more research is needed on the benefits 

of negative pressure wound therapy for treating pressure ulcers, but there is emerging evidence 

that this therapy may be helpful in assisting the healing of pressure ulcers. 

The use of growth factors and skin equivalents in the healing of pressure ulcers remains under 

investigation, although the use of cytokine growth factors (e.g., recombinant platelet-derived 

growth factor-BB [rhPDGF-BB]) and fibroblast growth factors (bFGF) and skin equivalents have 

been shown to be effective in diabetic and venous ulcers. Three small randomized controlled trials 

have suggested that growth factors had beneficial results with pressure ulcers, but the findings 

warrant further exploration.135–137 When we learn more about the healing cascade, the appropriate 

use of growth factors in pressure ulcer treatment may become clearer. 

The use of electroceuticals—highly refined electromagnetic fields that can accelerate the 

body’s natural anti-inflammatory response, thereby aiding wounds to heal faster—is showing 

some promising results. One animal study used a prospective, randomized, double-blind, 

placebo-controlled design to evaluate the effect of a specific noninvasive radiofrequency-pulsed 

electromagnetic field signal on tendon tensile strength at 21 days after transection in a rat 

model.138 This study found an increase in tensile strength of up to 69 percent (136.4 + 31.6 kg/cm2)

at the repair site of the rat Achilles' tendon at 3 weeks after transection and repair, compared with 

the value (80.6 + 16.6 kg/cm2 ) in nonstimulated control animals.Although electroceuticals are 

promising, additional research is needed to recommend them for pressure ulcer treatment. 

The use of therapeutic ultrasound for pressure ulcers has also been explored. A Cochrane 

review found three published randomized clinical trails using therapeutic ultrasound.139 It was 

concluded that there was no evidence of the benefit of ultrasound therapy in the treatment of 

pressure ulcers. Thus, additional studies are needed before this therapy can be supported. 

Evidence-Based Practice Implications 

Much progress has been made in identifying patients at risk for pressure ulcers. The use of 

pressure ulcer prediction tools (e.g., Braden Scale) have led to nursing’s sensitivity to earlier 

preventive measures. Research has shown that using the AHRQ guidelines on pressure ulcer 

prediction and prevention can lead to decreased incidence of pressure ulcers. Moreover, 

internalizing these guidelines throughout the health care system can lead to pressure ulcer 

reductions. 

Much progress has been made in understanding effective wound treatments. Treatments range 

from using traditional therapies (keeping the wound moist, appropriate repositioning, support 

surfaces, and proper nutrition) to the wise use of adjunctive therapies. Although many studies in 

pressure ulcer prevention and treatment have small sample sizes, there is a growing body of 

evidence to suggest that newer wound modalities can be effective in preventing and treating 

pressure ulcers. 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Research Implications 

Since the original publications of the AHRQ pressure ulcer prevention and treatment 

guidelines in 1992 and 1994, some progress has been made in our understanding of pressure ulcer 

care. Nursing research is needed to address many gaps in our understanding of pressure ulcer 

prevention and treatment. Many risk factors for pressure ulcer development have been identified; 

however, a hierarchy of risk factors has not been determined. Thus, research to determine the 

essential risk factors is still needed. There also remains a dearth of research determining the role 

that race and ethnicity may have on pressure ulcer development. A small body of research is 

emerging to suggest that people of color may have an increased risk for pressure ulcer 

development. Thus, nurses must actively recruit minority participants to further explore this 

important variable. Another promising area of nursing research is the use of pressure ulcer 

prediction tools. Although the Braden Scale was originally published nearly two decades ago, it 

remains the gold standard. As the patient population continues to change, nursing research is 

needed to develop and validate newer pressure ulcer prediction tools. 

There is a paucity of research on the effects of good skin care on pressure ulcer development. 

Randomized clinical trials are needed to validate specifics aspects of skin care (bathing schedules, 

cleansing solutions, water temperature, etc.) and their association with pressure ulcer development. 

Nursing research can also play a major role in closing the knowledge gap regarding optimal 

turning/repositioning schedules. Emerging research suggests that turning/repositioning every 2 

hours may not be necessary when using dynamic support surfaces. However, randomized 

controlled trials with large numbers of participants are greatly needed. Evidence is still unclear as 

to whether there are large differences in the effectiveness of various support surfaces (e.g., Group 

II) to prevent pressure ulcers. 

The role of protein-calorie malnutrition and pressure ulcer development remains understudied. 

Moreover, research into dietary supplements (vitamins, minerals, etc.) in the absence of a dietary 

deficiency is lacking. Additional nursing studies are needed to investigate whether the use of 

dietary supplements have any effect on pressure ulcer prevention. Recent nursing studies 

suggested that a comprehensive approach to prevention can lead to significant decreases in 

pressure ulcer incidence. However, studies investigating methods to sustain these decreases in 

pressure ulcer development are greatly needed. Additional research is also needed to further our 

understanding of risk level and titration of preventive measures 

Staging of pressure ulcers remains more of an art than a science. Additional nursing research 

is needed to determine effective methods of classifying pressure ulcer depth with good validity and 

reliability. There is also a dearth of nursing research on the optimal solution and frequency for 

cleansing a pressure ulcer. Moreover, nursing research is needed to determine the optimal method 

for removing devitalized tissue in a pressure ulcer. No randomized controlled trials could be found 

that determined the best debridement method for healing pressure ulcers. Nursing research has 

identified some clinical characteristics of infected pressure ulcers. However, additional research is 

needed on the most effective method for treating an infected or contaminated pressure ulcer. 

Numerous dressings are currently available to manage wound exudate. However, few 

randomized controlled trials have been conducted to determine optimal dressings within a 

classification (e.g., hydrocolloid, alginate). Many adjunctive therapies are currently being used, 

but few have extensive research to substantiate their effectiveness in healing pressure ulcers. 

Nursing research investigating the role of skin substitutes, growth factors, negative pressure 

wound therapy, and electroceuticals in healing pressure ulcers is greatly needed. Finally, nursing 

18 
Pressure Ulcers and Patient Safety

research evaluating the cost effectiveness of adjunctive treatments in healing pressure ulcers is 

warranted, given rising health care costs. 

Conclusion 

The prevention of pressure ulcers represents a marker of quality of care. Pressure ulcers are a 

major nurse-sensitive outcome. Hence, nursing care has a major effect on pressure ulcer 

development and prevention. Prevention of pressure ulcers often involves the use of low 

technology, but vigilant care is required to address the most consistently reported risk factors for 

development of pressure ulcers. The literature suggested that not all pressure ulcers can be 

prevented, but the use of comprehensive pressure ulcer programs can prevent the majority of 

pressure ulcers. When the pressure ulcer develops, the goals of healing or preventing deterioration 

and infection are paramount. Randomized controlled trials are needed to determine optimal 

management strategies dependent on stage and comorbidities/severity of illness. Nursing remains 

at the forefront of protecting and safeguarding the patient from pressure ulcers. 

Search Strategy 

The electronic databases MEDLINE® (1980–2007), CINAHL® (1982–2007), and EI 

Compedex*Plus (1980–2007) were selected for the searches. Evaluations of previous review 

articles and seminal studies that were published before 1966 were also included. Research 

conducted worldwide and published in English between the years 1930 and 2007 was included for 

review. Moreover, studies using descriptive, correlational, longitudinal, and randomized 

controlled trials were included. 

Author Affiliations 

Courtney H. Lyder, N.D., G.N.P., F.A.A.N., professor of nursing and professor of internal 

medicine, University of Virginia; e-mail: lyder@virginia.edu. 

Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N., B.C., C.W.O.C.N., F.A.P.W.C.A., F.A.A.N., 

clinical associate editor, Advances in Skin and Wound Care; e-mail: elizabeth@ayello.com. 

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Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key FinAllman 198622 Pressure ulcer risk factors Prospective cohort study Cross-sectional, pressure ulcer development Hospital, 21 years and older Hypoalbu

incontineremained independhaving a = 3.0, 3.1

Allman 199514 Pressure ulcer risk identification Prospective cohort study Prospective cohort study, time to in-hospital development of a Stage II or greater pressure ulcer Urban teaching hospital Age of 75 

nonblancpressure ulcer histincontinefold, lympcount < 1decreasewere signpressure univariate analyses 

Anthony 200070 Pressure ulcer 

prediction 

Prospective cohort study 

Noncomparative study, pressure ulcer development 

Skilled nursing facility, elderly 

Serum alpredictor developm

Baier 200353 Pressure ulcer 

prevention 

Quality improvement 

Prospective cohort study, implementation of AHRQ guidelines and pressure ulcer development 

Skilled nursing facilities, quality improvement teams in 29 nursing homes 

Quality improvement teams 

Six of eigmeasurewith percbaseline 11.6% to treatmenimproved 8.9%, anbetween each proand 12 fasignificanbaseline fewer decmeasure

26
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Fin

Bates-Jensen 1992127

Pressure ulcer healing 

Prospective cohort study 

Cross-sectional, pressure ulcer healing 

The Presinterrater at r = 0.9= 0.92 fo< 0.001). 0.99 for rrater two 

Baumgarten 200330

Pressure ulcer prevalence 

Prospective cohort study 

Prospective cohort study, pressure ulcer development among newly admitted residents from hospitals, home, or other settings. 

Skilled nursing facilities, 65 years and older 

Admissiosignificanpressure admissio

Bergstrom 198735 Pressure ulcer 

prediction 

Quality improvement 

Prospective cohort study 

Acute intensive care unit 

The Braden scale score and skin assessment 

Twenty-foadmitted pressure of 16 as 

Bergstrom 199213 Pressure ulcer 

risk identification 

Prospective cohort study 

Prospective cohort study, pressure ulcer presence or absence 

Skilled nursing facility, 65 years and older, 70% female 

Best preddevelopmscore (< pressureprotein in

Bergstrom 199242 Pressure ulcer 

prevention guidelines 

Published guideline 

Systematic literature review (Level 11) and consensus reports (Level 16), pressure ulcer prevention 

Hospital, skilled nursing facilities, and home care, elderly population 

Developmprevent p

Bergstrom 199843 Pressure ulcer 

prediction 

Quality improvement 

Prospective cohort study 

Tertiary care hospitals, Veterans Administration Medical Centers, and skilled nursing facilities 

The Braden scale score and skin assessment 

One hun(12.8%) dBraden ssignifican

those whthen thosof 18 is thprediction 

Berlowitz 198924 Pressure ulcer Prospective cohort Cross-sectional, Skilled nursing Factors a

27
28

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Fin

predictors study pressure ulcer development facility, elderly ulcer dev

level of cbed- or chypoalbu

Brandeis 199025 Pressure ulcers and mortality Retrospective cohort studies Use of large database, pressure ulcer development and mortality, hospitalization Skilled nursing facilities, elderly Pressure 

with an inbut not atransfers facilities t

Breslow 1993120 Pressure ulcers and dietary protein Prospective cohort study Nonrandomized trial, pressure ulcer healing Skilled nursing facility, patients ages 72 years and older with malnutrition Dietary supplement Significan

pressure 24% prot

Cuddigan 200110 Pressure ulcer incidence Systematic literature review Systematic literature review (Level 11), pressure ulcer incidence and prevalence Hospital, skilled nursing facilities, and home care Pressure 

hospitalsnursing fand hom

DeFloor 200461 Pressure ulcers Prospective cohort study Randomized controlled trial, pressure ulcer development Skilled nursing facilities, 60 years and older Turning every 2, 3, 4, or 6 hours using either standard mattress or 

viscoelastic foam 

The incidulcers wagroups. HStage II pin the 4-hviscoelasincidence varying b

Donaldson 200548

Licensed nurse-patient ratios and pressure ulcer development 

Retrospective Cross-sectional, 

pressure ulcer development 

Hospitals, adult, surgical, and definitiveobservation units, nurse-patient ratios 

Staffing ratios Impact of 

ratios did changes ulcer dev

Ek 198558 Pressure ulcers 

and massage 

Prospective cohort study 

Nonrandomized trial, pressure ulcer development, pressure ulcer development using massage 

Hospital, patients older than 60 years with and without cerebral hemorrhage 

Massage The effec

risk for pbetween patients. 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Fin

Fuhrer 199326 Pressure ulcer 

development 

Prospective cohort study 

Prospective cohort study, pressure ulcer development 

Community, patients with spinal cord injury (100 men and 40 women) 

Thirty-thrpresenteat least Svisually eindividuathe maximbeing sevseverity r(34.5%) wwere Staeither Staan ulcer and were in activitiproportiosevere uthan thei

Gardner 1999131 Pressure ulcers Meta-analysis Nonrandomized 

trial, pressure ulcer healing 

Electrical 

stimulation 

Rate of hfor electrand 9% feffect of 13% per over the 

Guralnik 198823 Pressure ulcer 

predictors 

Retrospective cohort studies 

Use of large database, pressure ulcer development 

Skilled nursing facilities, 55 years and older 

Pressure associateinactivitystatus, an

Hellwell 199780 Cytotoxicity 

evaluation 

Prospective cohort study 

Polymorphonuclear 

leukocytes (PMNs) 

Ten commercial wound cleaners 

The non-cleansers to 1,000, antimicro10,000. 

Horn 200547 Nurse-patient 

ratios and pressure ulcer development 

Retrospective Cross-sectional, 

pressure ulcer development 

Skilled nursing facility, registered nurse-patient ratios 

Staffing ratios More reg

resident wdevelopmulcers. 

Johnson-Pawlson 199646 Nurse-patient ratios and 

pressure ulcer development 

Retrospective Cross-sectional, 

pressure ulcer development 

Skilled nursing facility, registered nurse patient ratios 

Registered nurse staffing ratios 

The ratio residents measure deficienc

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Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key FinKloth 1988129 Pressure ulcer healing Prospective cohort study Randomized controlled trial, pressure ulcer healing Skilled nursing facility, patients ages 20 to 89 years, Stage IV pressure ulcers High voltage monophasic pulsed current Patients 

at a meahealed 17.3 weekgroup incof 11.6% 28.9% ovweeks. Lyder 199820 Pressure ulcer prediction and prevention Unpublished research Retrospective cohort study (Level 9), pressure ulcer development Hospitals, Medicare beneficiaries The num

associatedevelopm

with ≥ thrassociateincidence ulcers, in one or tw

Lyder 200112 Pressure ulcer 

prevention 

Quality improvement research 

Retrospective cohort study (Level 9), pressure ulcer incidence 

Hospital, Medicare beneficiaries 

AHRQ pressure ulcer prevention guidelines 

Hospital preventiofor daily srisk identpressurenutritionareposition(66.2%). 

Lyder 200251 Pressure ulcer 

prevention 

Retrospective and prospective quasiexperimental 

Pressure ulcer prevention program 

Two long-term care facilities (A = 150 beds, B = 110 beds) 

Pressure ulcer prevention program 

An 87% din facility 76% decfacility B 

Lyder 20047 Pressure ulcer 

prevention 

Quality improvement research 

Retrospective cohort study (Level 9), pressure ulcer development 

Hospitals, Medicare beneficiaries 

Implement systematic risk assessment, repositioning, support surfaces 

Statisticathe identpatients, or chair-bconsults and stagpressure followup abstractio

Meaume 2005108 Silver in chronic 

wounds 

Prospective cohort study 

Randomized (stratification according to 

13 centers with 99 participants 

Silverreleasing hydroalginate 

The studwounds wwith silve
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Fin

wound type) opened label multicenter comparative two-arm parallel-group 

dressing dressing 

on wound 

Ooka 199568 Support surfaces Prospective cohort 

study 

A new-product evaluation with convenience sampling 

Surgical intensive care unit 

Dynamic and static mattresses 

All three compara

Pang 199836 Pressure ulcer 

risk identification 

Prospective cohort study 

Prospective cohort study, validity of pressure ulcer prediction scales 

Hospital, 21 years and older, pressure ulcer free 

Pressure ulcer prediction scales 

Both the scales ha(81% and whereas high sens(62%). Ahigh neg(>90%), better po

Perneger 200238 Pressure ulcers Prospective cohort 

study 

Cross-sectional, pressure ulcer development 

Teaching hospital, patients older than 60 years 

The FRAfriction, awas lineaulcer riskreceiver curve (0.Norton (0(0.74; 

P = 

Reddy 200662 Pressure ulcer 

prevention 

Systematic literature review, pressure ulcers 

Systematic literature review 

59 randomized controlled trials grouped into three categories 

Giving cusupport soptimizinhydration appropria

Romanelli 2003107

Pressure ulcer infection 

Systematic literature review 

Systematic literature review 

Use of syinfected pbased on should be pathogenof antimicto the proorganism

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Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key FinRosen 200588 Pressure ulcer prevention Quality improvement Prospective cohort study, pressure ulcer development Skilled nursing facilities, elderly Staff empowerment, real-time feedback Empowe

feedback of new pr

Roth 2004123 Pressure ulcer and pain Prospective cohort study Cross-sectional, pressure ulcer pain McGill Pa

sensitive single ratMoreovepositively and pain positively 

Schoonhoven 200239 Pressure ulcer risk Prospective cohort study Prospective cohort study, pressure ulcer development Hospitals, patients admitted to surgical, internal, neurological, or geriatric units, 18 years and older The wee

with pres

confidenc

The area operating 0.56 (0.5scale, 0.5

Braden s0.66) for 

areas for excluding 

preventivdevelopin

excluding 0.71 (0.6

0.78), anrespectiv

using the points, th

was 7.0% the Brade

Waterlow 

Stotts 2001126 Pressure ulcer 

healing 

Retrospective Cross-sectional, 

pressure ulcer healing 

Skilled nursing facility The Pres

Healing t74% of thover a 10and 40% healing vperiod in 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Fin

tool is a vof pressu

Thomas 199615 Pressure ulcers 

and mortality 

Prospective cohort study 

Prospective cohort study, time to death from admission to 1-year posthospital discharge. 

Urban teaching hospital 

Developmpressure greater ri(59.5% vHoweverdevelopmindependdecreasefor other 

Torra 200555 Hyperoxygenated 

fatty acid 

Prospective cohort study 

Double-blind randomized clinical trial 

Multicenter Hyperoxygenated 

fatty acid preparation 

Pressure study wagroup vegroup (P 

Xakellis 199849 Pressure ulcer 

prevention 

Quality improvement research 

Costeffectiveness evaluation 

77-bed long-term care facility 

A guidelinebased pressure ulcer prevention protocol 

Pre-protodevelopePost-protdevelope

Xakellis 200150 Pressure ulcer 

guidelines 

Retrospective and prospective quasiexperimental longitudinal 

Cost effectiveness of a guideline-based pressure ulcer prevention protocol over time 

77-bed long-term care facility 

A guidelinebased pressure ulcer prevention protocol 

Time to uamong th8.81, P = healing (lCost of tr5.5, P = < increased 

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