Pressure ulcers: assessment and management

1. John has motor neurone disease and has developed grade 3 pressure ulcers on his buttocks. He spends
most of the day in a custom built wheelchair. His appetite isn't as good as it was. In addition, his external
catheter leaks occasionally. What is the most likely cause of his pressure ulcers?
Pre-test answer
a.

Inadequate nutrition

b.

Urinary incontinence

c.

Unrelieved pressure

Your answer

Correct answer

That's not right. The correct answer is c.

The pressure ulcers are grade 3 and are sited directly over the bony prominence of the ischial
tuberosities. This is the classic appearance of unrelieved pressure when seated.
Poor nutritional status can contribute to the development of pressure ulcers, but it has not been
established that it is the main cause. [ 3 ] The site, grade, and appearance of the ulcers all point to
unrelieved pressure being the cause.
Incontinence, both urinary and faecal, will attack the integrity of the skin. This will produce a supercial
and erosive appearance. These ulcers are deep and are due to unrelieved pressure.

2. You are asked to visit a woman in a nursing home with a pressure ulcer. On examination the ulcer is
supercial and presents clinically as an abrasion with skin loss involving epidermis and dermis in a
buttery distribution to her buttocks. What grade of pressure ulcer is this?
Pre-test answer
a.

Grade 1

b.

Grade 2

c.

Grade 3

d.

Grade 4

Your answer

Correct answer

That's not right. The correct answer is b.

Grade 2 ulcers are dened as partial thickness skin loss involving epidermis, dermis, or both. The ulcer is
supercial and presents clinically as an abrasion or blister. [ 6 ] Pressure ulceration such as this is also
termed as moisture lesions and management is aimed at restoring the barrier function of the skin.
Grade 1 ulcers are dened as non-blanchable erythema of intact skin. Discoloration of the skin, warmth,
oedema, induration, or hardness may also be used as indicators, particularly on people with darker skin. [
6]

Grade 3 ulcers are dened as full thickness skin loss involving damage to or necrosis of subcutaneous
tissue that may extend down to but not through underlying fascia. [ 6 ]
Grade 4 ulcers are dened as extensive destruction, tissue necrosis, or damage to muscle, bone, or
supporting structures with or without full thickness skin loss. [ 6 ]

3. You are asked to review Isobel, an 82 year old woman who has developed a blister on her heel. She has
dementia and is nursed at home. She is bed bound and gets restless at times. She is nursed on a pressure
reducing foam overlay. She is an ex-smoker. What is the most likely cause of the blister?
Pre-test answer
a.

Poor vascular status

b.

Unrelieved pressure to the heel

c.

Friction and shear

Your answer

Correct answer

That's not right. The correct answer is c.

Pressure may well have been a contributing factor, but the formation of a blister reveals that the major
cause was friction and shear. This is most likely due to Isobel's restlessness or her inappropriate
repositioning by the carers.
Poor vascular status may have been a contributing factor in the development of the pressure ulcer. As a
smoker, Isabel will be at increased risk of peripheral vascular disease. But blister formation indicates that
this would not have been the main cause.
However, as part of the assessment process, obtaining the ankle brachial pressure index using a Doppler
would be useful to establish the extent of the problem and impact on healing.

4. One of your patients was recently discharged from hospital following a hip replacement. He has a
pressure sore over his heel. Despite this he is trying to increase his mobility, but the pain is worse at night.
What should you suggest as appropriate equipment to relieve pressure over his heel?
Pre-test answer
a.

A water lled glove

b.

A sheepskin bootee

c.

A foam or air lled heel protector

Your answer

Correct answer

That's not right. The correct answer is c.

Providing pressure reduction directly to the heel is an ecient and cost effective approach to pressure
ulcer prevention. There are a number of products available on the market. [ 17 ]
A water lled glove is not recommended; it's surprising that they continue to be used even when suitable
pressure relieving equipment can be provided. It is not a practical solution, because the glove is not
stable and the heel will keep nding its rest on the mattress.
The use of sheepskin bootees is not advised now; when washed, their ecacy is reduced.

5. A 50 year old man has a pressure ulcer on his buttock. He is taking paracetamol regularly but it is still very
painful. What should you suggest for his pain?
Pre-test answer
a.

Your answer

Correct answer

Try stronger analgesia such as paracetamol/dihydrocodeine

combinations

b.

Add a non-steroidal anti-inammatory drug

c.

Referral to the local pain clinic

That's not right. The correct answer is a.

Clinicians used to think that pressure ulcers are not painful. A recent study reported that pain was
signicant and disabling for people with pressure ulcers. [ 18 ]
If simple analgesia, such as paracetamol, is insucient you should start patients on stronger analgesia
rst, such as paracetamol/dihydrocodeine combinations. If this doesn't control the pain, consider
referring the patient to a specialist.
Non-steroidal anti-inammatory drugs tend to cause peripheral (or dependent) oedema and don't seem
to help pressure ulcer pain.

6. Dorothy has severe osteoarthritis and is mainly conned to bed. She weighs around 25 stone and has
been assessed as high risk for pressure damage. What equipment would be suitable for her needs?
Pre-test answer
a.

Pressure reducing foam mattress

b.

Alternating pressure or low air loss overlay

c.

Alternating pressure or low air loss mattress

Your answer

Correct answer

That's not right. The correct answer is c.

Because of Dorothy's weight, she would need the depth of a mattress replacement. It is important that
her weight is checked against the weight limit of both the mattress and the bed. Also, a proling (electric)
bed would electrically autocontour for the patient. This will help repositioning, reduce shear forces and
slippage, and reduce manual handling issues. [ 19 ] [ 20 ]
A pressure reducing foam mattress is suitable for low to medium risk patients and is considered standard
for most hospitals now. This would not be suitable for Dorothy because of her weight and high risk.
Because of Dorothy's weight, an alternating pressure or low air loss overlay would not be suitable. She
would bottom out (atten the cells or overlay) and her bottom would, in effect, rest on the mattress
below.

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