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Pressure Injuries

Pressure Ulcers - Definition, Assessment, and Prevention

A handy guide to defining, assessing, and preventing pressure injuries in senior care communities.

According to NPIAP, “60,000 patients die every year as a direct result of pressure injuries” and lawsuits after death from a pressure injury are the “2nd most common claim”. We can’t all be wound care qualified, but everyone with a hand in the care of seniors should have a working knowledge of identifying, assessing, and implementing pressure reduction measures. Prevention and early detection of pressure injuries is the best way to protect your patients from the pain, indignity, and even fatality that can result from pressure injuries.Therefore, ensuring all care staff are adequately educated on the risk factors, complications, severity levels (stages of pressure injuries), and prevention measures is vital to any care setting.

That’s why we’ve created this guide on the definition and assessment of pressure injuries. We’ll also cover some prevention measures to assist in implementing skin care strategies.


Commonly known as pressure sores or bedsores, the National Pressure Injury Advice Panel defines pressure injuries (PI) in the following way.

“A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”

Risk Factors

As the name suggests, pressure injuries are caused primarily by constant pressure of some sort that damages tissue cells and results in varying amounts of dead tissue. While not all pressure wounds are preventable, there are a number of risk factors that can make a person more likely to develop a pressure injury or to develop them faster. It’s important to consider all risk factors when assessing a person’s risk, but there is no way we can completely prevent all PIs.

Accora’s own Heidi Sandoz has this to say about the continuous fight against pressure injuries in senior care:

“One thing that you always need to remember is that until we can find a way of free-floating people in mid-air or in water and safely be able to deliver their care, we’re highly unlikely to be able to eliminate pressure ulcers. We can do plenty of things to minimize the likelihood of them happening, but we cannot get rid of that likelihood altogether.”

Mobility or lack thereof

The primary factor that creates a risk of pressure injuries is immobility. Immobility might be due to several factors such as in some high-risk populations like the elderly, the critically ill, and those with physical impairments. When a person is mobile and can move themselves with ease, they can prevent their own pressure injuries in many cases where specific devices are not involved. When a person cannot move independently and must rely on others to move them periodically between a bed and chair or even to reposition themselves then the likelihood of developing pressure injuries is much higher.

Underlying health issues

All cells, regardless of function, require three things to survive and thrive: Food, oxygen, and water. That’s the very reason why residents with any sort of respiratory, vascular, or digestive problems will be at an increased risk of developing a pressure injury. People with respiratory issues may have a lower oxygen level in their tissue cells and the same could be said of those with poor vascular and cardiac health where pumping adequate quantities of blood around the body is impaired. Without oxygen, cells weaken, and damage can occur at an increased rate, resulting in dead tissue. This lack of oxygen and perfusion contributes to the development of these injuries.

Residents who are cognitively impaired may also be at a higher risk of developing pressure injuries but not as a direct consequence of the condition. Those with Dementia, or Alzheimer’s, for example,might be able to feel where constant pressure is occurring and become uncomfortable, but unless they can tell someone that they are experiencing discomfort, or can adjust their position themselves, the damage can quickly occur.


Depending on the risk factors such as underlying conditions, environment, and equipment used to mitigate pressure, cells can become damaged and die within one hour of exposure to external pressure. That’s why it’s important to consider all aspects of the risk of pressure injuries including independent mobility and time spent in one position. Many factors affect how quickly a resident can develop a pressure injury, so what might take three hours for one person to become affected could take another person just one. Nevertheless, the longer a person is allowed to remain in the same position, the higher the likelihood of them developing this type of injury.


Pressure ulcers, wounds, and injuries can occur when cell damage happens due to pressure applied by medical or other devices. ‘Device’ is an umbrella term and refers to anything that is touching that patient that is not organic. Personal effects like spectacles or jewelry can create or worsen a pressure wound. Medical devices such as oxygen tubes, masks, catheters (yikes!), and splints can all cause pressure injuries to develop, and bed junk like bottle tops or needle caps can easily become lost amongst the folds (sheets or skin) and cause injury.


Gravity and shear force can also exacerbate the risks of pressure ulcers. Gravity is really at the center of blame for pressure wounds occurring. If we were all floating in space, then stray objects wouldn’t have the opportunity to exert such a force on our skin for a prolonged period. Essentially, either the downward force acting upon the patient or the device creates the pressure which can damage cells. Minimizing the effects of gravity upon the localized area is key to the treatment of pressure ulcers should they occur.

Shear force refers to the process of a resident sliding down when in a seated or semi-reclined position. As the person slides downwards towards the foot of the bed or chair, the spine moves downwards while the skin stays more or less put and in contact with the surface of the bed or chair. This causes stress on the blood vessels and cells between the spine and the skin surface and can prevent them from receiving an adequate oxygen supply and eventually causes necrosis of the cells resulting in a pressure wound.


In the US we typically refer to the stages of pressure injuries to ascertain the pressure ulcer prevalence. Pressure injuries are classified by stages 1 through 4 and then designated as "unstageable" for wounds where it's not yet possible to see the extent of the necrotic tissue. There is also the “suspected deep-tissue injury” category for when you identify an area of discolored, intact skin or a blood-filled blister but this does not fall into one of the other categories.

It is prudent to note at this point that residents with darker skin tones may be at a greater risk of suffering pressure injuries, not because of a predisposition but because they are much harder to identify, especially in the early stages. So, the guidance from this point should be taken with the understanding that not all skin tones will exhibit the exact appearance described. You can find additional advice on staging pressure injuries for different skin tones on the NPIAP website.

A representation of four stages of pressure inuries
Four stages of pressure injury

Suspected deep tissue damage

Purple or maroon localized discoloration of the skin. This could present as intact skin or as a blood-filled blister which can be painful, firm, mushy or warmer or cooler than adjacent healthy tissue.

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

The damage May be subtly visible at the skin surface level. It would typically manifest in a circular or symmetrical redness which does not return to the normal pigment when a thumb is gently pressed on the area. The key thing to observe when assessing a category one pressure ulcer is that if the skin surface appears pink, then the cells underneath near the bone will actually be red, and if there is redness on the surface, then the cells deeper down will be purple and for lack of a better word, already choking. Because skin surface cells are better equipped to handle pressure than muscle cells, the damage seen from the surface should not be underestimated because the majority of the cell deterioration will be well below the surface where it is less visible.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis

Again, discoloration is visible below the skin surface (but easier to see in lighter skin tones) but the adipose (fat) is not visible, nor are the deeper tissues. Commonly misdiagnosed as moisture-associated skin damage such as those which can occur from incontinence. The key thing to look out for here is that the wound bed is visible and that the wound is noticeably reddening, is moist, and note that it can appear as a moisture-filled blister at this stage.

Stage 3 Pressure Injury: Full-thickness tissue loss

Fat is now visible and rolled wound edges are often present. Slough may be present but does not obscure the extent of the damage. Bone, muscle, tendon, cartilage, or ligament should not be exposed.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss

An image of teo severe sacral pressure wounds

Fascia, muscle, tendon, cartilage,ligament, or bone is now exposed and visible in the ulcer. Again, if the eschar or slough obscures the extent of the tissue loss, then it is categorized as an unstageable wound.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

Unstageable is the term for pressure wounds in which cases it is not possible to identify the extent of the tissue damage because it is obscured by slough or eschar. If the outer tissues were removed, then a stage 3 or 4 pressure injury will be revealed. However, you should consult a wound care specialist before removing or softening the eschar to expose the necrotic tissue as in some situations it is unwise to do so.


When considering the prevention of pressure injuries, there are many assessment methods care professionals use to understand the risk to residents. Some common tools used for identifying the level of pressure risk of a resident are the Waterlow, Braden, and Norton scales.

While all these methods have their merit, it is important not to let your clinical judgment be overruled by them, as none of them are infallible at identifying risk. You also need to think about when you perform a risk assessment. Dr. Elizabeth Ayello recommends doing a risk assessment for residents upon admission and reassessing frequently based on the patient’s acuity. Also, reassess the risk of pressure ulcers when any significant change occurs in the resident’s condition or if they transfer from one unit to another.

One key equation you could use to demonstrate the need for pressure care prevention is the following:

Start by assessing the various pressure points in contact with the resident where there are bony protrusions. For someone who is lying flat on their back, those pressure points would likely be:

  • The back of the head
  • The shoulders
  • The elbow
  • The buttocks
  • The heel

The next thing to establish is what length of time is the resident lying there without moving or being moved. Of course, the less time they spend in the same position, the lesser the risk of developing pressure ulcers in those identified areas. Then identify the risk that the surface on which they are lying creates. The hard floor will exact more pressure than a foam mattress for example.

The heel area is a common site of pressure injuries

As we’ve said, we cannot prevent all pressure injuries, but there are many interventions we can perform to decrease the risk for patients. That’s why risk assessment is so vital for successful pressure ulcer prevention. If a resident is actually a high risk but is designated as low or no risk through error, the impact on their health could be disastrous. Encouraging mobility is one of the best ways to prevent pressure injuries, but patients who have limited or no independent mobility must rely on being regularly moved either by equipment or nursing staff to relieve pressure.

Distribution is key

In terms of pressure ulcer prevention and management, positioning the resident in ways that evenly distributes pressure and redistributes it away from pressure points is one key way to prevent ulcers from occurring in patients at risk. Since residents typically spend the majority of their time in bed or in a chair of one kind or another, Accora provides both beds and geriatric chairs which offer superior pressure distribution and optimal care positions for day and night pressure care needs.

Pressure-reducing BodyMove technology

Our unique BodyMove™ technology mimics the way the human body naturally moves and provides gentle expansion where other products compress the sacral area. BodyMove™ technology reduces friction and shearing when moving the bed from lying to sitting. This action maximizes postural support and prevents skin and tissue damage. In one study, the Empresa FloorBed was proven to reduce pressure over the sacral area by up to 23 percent compared to a standard nursing bed, and that’s even without a pressure mattress. 

Get a move on

Ensuring that residents who are not able to reposition themselves independently are moved frequently will aid in the prevention of pressure injuries developing. The frequency of this necessity should align with the severity of risk identified in your pressure risk assessment. There are many schools of thought about how often to turn or reposition residents and which positions they should rest in but the point is that the longer someone stays in a single position, the greater the risk of them developing a pressure-related injury. Factoring in a regular and standardized turning schedule based on risk level will help to effectively prevent many preventable pressure injuries across your facility.

Check (and double check) devices

Some lesser-known risk areas for device-related pressure injuries are:

·       The nose – think oxygen tubes putting pressure on the nose tissue for long periods of time

·       The ears – straps from masks or spectacle arms can cause pressure on the ear tissues against the cartilage

·       Urethra – improperly deployed catheters or ones that have been accidentally shifted during other care tasks can cause painful and distressing pressure injuries.

Although it’s always good to keep a check on high-risk areas over a bony prominence, it is also important to regularly check that medical devices are not causing preventable pressure which can lead to tissue damage.

Clear the deck

Making a routine search for bed junk while carrying out other checks can be a very worthwhile exercise in terms of PI prevention. Tiny pieces of rubbish can easily become embedded in the skin surface and cause deeper damage. Keeping stock of what non-organic items are allowed near the bed areas and ensuring all rubbish is appropriately cleared will go a long way to stop bed junk from causing a very real problem for your residents.

Educate the team

Arguably the most important method of pressure injury prevention is to prioritize the education of every member of your care team from the cleaners to the nurses. Regardless of job title, it’s vital that every member of your facility’s workforce is aware of the danger of pressure injuries and has a basic knowledge of prevention.When people are given the training they need, you’ll be surprised at how so-called unskilled laborers might notice something that skilled nurses miss. Early detection and prevention of pressure injuries benefits everyone including the resident, the nursing staff, and the stakeholders of the care community, so don’t underestimate the power of education.

Final thoughts

We hope this resource has proven useful for those involved in long term and acute care of seniors. At Accora, we really care about stopping all preventable pressure ulcers and pressure-related deaths. So, check back on our blog regularly for more advice and information on pressure ulcer prevention and the management of pressure ulcers, or follow us on LinkedIn to stay up to date with our news and the latest free resources from Accora. For more information about our range of pressure-relieving products, head to our website.


Pressure Injuries
Accora Team
FloorBed technology to help skilled nursing, rehabilitation and long term-care facilities prevent falls and fall-related injuries.
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Amy Bruggemann
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Best practice pressure injury prevention and documentation
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Best practice pressure injury prevention and documentation
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Best practice pressure injury prevention and documentation