what is a press ulcer

What Is a Pressure Ulcer? Five Things All Caregivers Should Know

While many types of wounds are observed in the home care setting, pressure ulcers top the list. It is estimated that 1-3 million Americans experience pressure sores each year, mostly senior citizens and others with conditions that limit their mobility.

Not only are pressure ulcers worrisome and painful, they can be deadly if left untreated. In fact, complications from untreated bedsores account for about 60,000 deaths per year. [I]

To prevent pressure sores, or bed sores as they are often called, it’s important to understand how to identify, treat, and prevent them from happening in the first place. Here are five things you should know when caring for the elderly.

Pressure Ulcer Information

Identifying Pressure Ulcers

So what is a pressure ulcer? The Mayo Clinic defines pressure ulcers, also called decubitus ulcers, as injuries to the skin and underlying tissue because of prolonged pressure on the skin.

These ulcers are especially troublesome in spots where the skin covers bony areas of the body. For people using wheelchairs, common areas include the shoulder blades and spine, buttocks or tailbone, and the backs of the arms and legs where contact is made with the chair. For bedridden patients, sores often occur on the shoulder blades, hips, tailbone, lower back, sides or back of the head, heels, and ankles. [ii]

For many elderly individuals with limited mobility, pressure sores can become chronic and continue for long periods of time, even lasting for the rest of the patient’s life. By keeping the lines of communication open, the patient, caregivers, family members, and healthcare providers can work as a team to identify risks and develop a plan of action to prevent and treat pressure sores before they become life-threatening.

Warning Signs and Stages of Pressure Ulcers

Warning signs that a pressure sore is forming include swelling, areas of skin that feel warmer or cooler to the touch, changes in skin color or texture, tenderness, and pus-like drainage. If you observe any of these warning signs, let the patient’s health care partner know.

Pressure ulcers are characterized in four grades or stages:

Stage 1 Pressure Ulcer:

The skin is inflamed but unbroken. Redness, discoloration, induration, oedema (excess of watery fluid), or hardness may be observed.

Stage 2 Pressure Ulcer:

The first layer or two of skin (epidermis and dermis) are broken, giving the appearance of an abrasion or blister.

Stage 3 Pressure Ulcer:

Full-thickness skin loss, including damage to the necrosis of subcutaneous tissue, is now occurring and may even extend down to the underlying fascia.

Stage 4 Pressure Ulcer:Understanding What Causes Pressure Ulcers

You’ve heard the adage, “An ounce of prevention is worth a pound of cure.” Learning the risk factors, and how to mitigate the risk, is an important part of preventing bedsores from happening altogether. Common risk factors include: [iii]

  • Medical conditions that prevent proper blood flow, like diabetes and peripheral vascular disease
  • Lack of mobility
  • Poor nutrition and/or hydration
  • Lack of sensory perception

How to Prevent Pressure Ulcers

Knowing the common causes of pressure sores helps with prevention of those sores. Here are some prevention tips you can implement: [iv]

Shift positions every couple of hours:

If a patient is bedridden, this can involve moving from one side of the body to the other. Pillows and other support items can be used to help the individual stay in the correct position. If the patient spends a good deal of time in a chair, switching positions and taking breaks by moving around and laying down can help alleviate pressure to prone areas

Encourage exercise:

Since pressure inhibits blood supply to an area of the body, it makes sense that exercise is important to encourage blood flow. This can seem like quite a challenge for patients with limited mobility, but even simple range of motion activities for arms and legs can be helpful.

Keep skin dry, clean, and moisturized:

By keeping the skin clean, dry, and moisturized, you can help prevent pressure sores from forming. Always use a soft sponge or cloth and mild soap for cleansing, paying special attention to hard-to-reach areas. Pat areas dry instead of rubbing to minimize skin irritation. Apply a skin protectant or moisturizing cream to the body daily to keep skin from drying out.

Focus on proper nutrition and hydration:

Arm your patient with plenty of water and a diet high in vitamins, minerals, and protein to help his or her body function at its peak.

Pay special attention to clothing:

Clothing that is too tight or has zippers, buttons, or other features that can put unnecessary pressure on areas of the body should be avoided. Check to make sure that the patient’s clothes are not wrinkled or bunched up at pressure points. [v]

Use pillows as a barrier between pressure points:

When we sleep on our side, a good deal of pressure is applied to areas of the body that are touching, such as knees, ankles, and heels. To help alleviate pressure, apply pillows between those areas.

Lower risk with pressure-relieving support surfaces:

There are two types of pressure-relieving supports that have proven to be beneficial in the reduction of pressure sores.

The first are cushions and mattresses made with a special foam or gel, and overlays made of gel, silicone, wool, or sheepskin. These surfaces have softer, more body-conforming properties, which make them effective in reducing the risk of pressure sores.

The second are mattresses and overlays with alternating pressure systems, which can apply pressure to different parts of the body at regular intervals to prevent pressure from being applied to one area for an extended period of time. [vi]

How to Treat Pressure Ulcers

Unfortunately, even when you are diligent in trying to prevent pressure ulcers from developing, they can still form and must be quickly assessed so an appropriate treatment plan can be put in place. When it comes to caring for wounds, the focus is to provide the best conditions to promote natural healing and skin repair. Treatments will vary based on the patient’s plan of care with input from their physician. Here is some additional treatment information for each stage.

Stage One Pressure Ulcer Treatment

Typically stage one treatment includes the use of a transparent film designed to be water tight and easy to inspect. This film, used for non-draining ulcers, reduces friction on the affected area and is changed every five to seven days. Patients should stay off the affected area completely.

Caregivers can help in the following ways:

  • Keep the area clean and dry.
  • Encourage adequate nutrition and hydration.
  • Find and remove the cause of the pressure sore.
  • Inspect the area at least twice per day.

If these instructions are followed, the sore should be resolved in about three days. If it is still present, contact the healthcare provider.

Stage Two Pressure Ulcer Treatment

In stage two, if the wound has a moderate amount of drainage, an opaque or transparent hydrocolloid dressing is applied. This dressing adheres to skin with no separate taping and is biodegradable and non-breathable.

Hydrocolloid dressings have gel-forming agents that create an absorbent waterproof wafer which keeps the wound moist and prevents fluid accumulation at the surface. This dressing is not suitable for pressure wounds with heavy drainage.

In addition to dressing the wound, caregivers should follow the additional protocols for stage one. The healing time frame for stage two pressure sores is anywhere from three days to three weeks.

Stages Three and Four Pressure Ulcer Treatment

Two types of dressings are commonly used to treat stage three and four pressure ulcers—alginate and foam.

Alginate dressings:

Typically used for wounds with moderate drainage, these dressings are dry when applied but grow larger as they draw in fluids. This is beneficial because it helps clear out the wound, encourages new skin growth, keeps it moist, and offers protection from harmful bacteria that can cause infections.

Silver alginate dressings are applied in cases where the wound is infected or is at high risk of becoming infected. Alginate dressings need to be changed every one to three days or when fluid begins to seep out from the edges.

Foam dressings:

For very leaky wounds, highly absorbent foam dressings are commonly applied. Foam dressings are best utilized when drainage is at its peak and only need to be changed every two to four days. Foam dressings shouldn’t be used if there is too little drainage because they can dry out the area and inhibit the healing process.

In some cases, surgery will be necessary in stages three or four to close the wound.

Caregivers should continue to follow the additional protocol outlined for stage one treatment.


Preventing, identifying, and treating pressure ulcers should be a team effort. With effective communication among healthcare partners, caregivers, family members, and the patient, you can help ensure comfort and a better quality of life.

[i] http://www.npuap.org/wp-content/uploads/2017/03/Padula-William-NPUAP-13FEB17.pdf

[ii] https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-causes/syc-20355893

[iii] https://www.ncbi.nlm.nih.gov/pubmed/20359262

[iv] https://www.advancedtissue.com/5-tips-for-preventing-bed-sores-in-bedridden-patients/

[v] https://medlineplus.gov/ency/patientinstructions/000147.htm

[vi] https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0079409/