In which stage is a pressure ulcer identified as a red or bruised area of skin?

• Overview
• Symptoms and Causes
• Diagnosis and Tests
• Management and Treatment
• Prevention
• Outlook / Prognosis
• Living With

Overview

What is a pressure injury?

A pressure injury (also called a bedsore, pressure ulcer, pressure sore, or decubitus ulcer) is an area of injured skin. A pressure injury happens when force is applied on the surface of the skin. This force can be a constant pressure on an area of skin or a dragging (shearing) force between the skin and another surface. These injuries usually happen over bony parts of the body (hips, heels, tailbone, elbows, head and ankles). A pressure injury can become life-threatening if it advances to a deep wound or becomes infected.

What are the stages of a pressure injury?

There are four stages that describe the severity of the wound. These stages include:

• Stage 1: This stage is discolored skin. The skin appears red in those with lighter skin tones and blue/purple in those with darker skin tones. The skin does not blanch (turn white) when pressed with a finger.
• Stage 2: This stage involves superficial damage of the skin. The top layer of skin is lost. It may also look like a blister. At this stage, the top layer of skin can repair itself.
• Stage 3: This stage is a deeper wound. The wound is open, extending to the fatty layer of the skin, though muscles and bone are not showing.
• Stage 4: This stage is the most severe. The wound extends down to the bone. The muscles and bone are prone to infection, which can be life-threatening.

Who is at risk for developing pressure injuries?

• People with a limited amount of mobility or a total inability to move. Those in wheelchairs or bedridden are at particular risk and need to be moved or turned regularly.
• Those with prosthetic (artificial) limbs. If the device does not fit properly, the skin can be irritated and a pressure injury can develop.
• People with a loss of sensation. They are at risk because they may not feel the pressure being applied to the skin. As a result, they may not move, which could worsen the damage.
• Those with malnutrition. Wound healing is slowed when nutritional needs are not met.
• The elderly. As people age, the skin naturally becomes thinner and more easily damaged.

Symptoms and Causes

What are the causes of pressure injuries?

Pressure injuries are caused when a force is applied to the skin, causing damage to the tissue. Several types of force include:

• Pressure: Constant pressure on the skin results from remaining in the same position for a prolonged period of time.
• Shear: Shear damage or a dragging force can occur when the head of the bed is raised and the body slides down. The skin sticks to the sheets, but internal structures are damaged.
• Moisture: Fluids (sweat, urine, fecal matter) that remains on the skin can cause the skin to become overly wet, which increases the risk for pressure injury development.

What are the symptoms of pressure injuries?

The symptoms of pressure injuries can include:

• Changes in skin color (non-blanchable redness in lighter skin tones and non-blanchable blue/purple skin in darker skin tones)
• Skin swelling, pain or tenderness
• Skin that feels cooler or warmer to the touch than other areas
• Skin loss, exposing deeper layers of skin
• Pus-like drainage from an open area of skin

Diagnosis and Tests

How are pressure injuries diagnosed?

Pressure injuries are diagnosed by your healthcare provider during a physical exam.

Management and Treatment

How are pressure injuries treated?

Pressure injuries can be treated in many ways depending on the stage. Once the stage and severity of the wound is determined, it must be cleaned, usually with a saline solution. After the wound is cleaned, it needs to be kept clean, moist, and covered with an appropriate bandage. There are several different types of bandages your doctor may use to dress the wound. These include:

• Water-based gel (hydrogel) with a dry dressing
• Foam dressing
• Hydrocolloid dressing
• Alginate dressing (made from seaweed)

Sometimes debridement is needed. This is a process of ridding the wound of dead tissue. Debridement is an important part of the healing process. It changes the wound from a long-lasting (chronic) one to a short-term (acute) wound. There are several types of debridement. These methods include:

• Ultrasound: Using sound waves to remove the dead tissue.
• Irrigation: Using fluid (often pressurized) to wash away dead tissue.
• Laser: Using focused light beams to remove the dead tissue.
• Biosurgery: Using maggots to eliminate bacteria from the wound.
• Surgery: Using surgery to remove the dead tissue and close the wound.
• Topical: Medical-grade honey or enzyme ointments.

Prevention

How can pressure injuries be prevented?

The development of pressure injuries can be prevented through careful observation of the skin and frequent repositioning in those who can’t turn themselves. Tips to prevent pressure injuries include:

• Keeping the skin clean and clear of bodily fluids.
• Moving and repositioning the body frequently to avoid constant pressure on bony parts of the body.
• Using foam wedges and pillows to help relieve pressure on bony parts of the body when turned in bed.
• Maintaining a healthy diet to avoid malnutrition and to assist in wound healing.

Outlook / Prognosis

What are the long-term consequences of a pressure injury?

If the wound becomes infected, the infection can spread to other parts of the body. Several conditions that may occur if an infection spreads include:

• Cellulitis: An infection of the skin.
• Osteomyelitis: An infection of the bone.
• Bacteremia: An infection of the blood.
• Meningitis: An infection of the brain and spinal cord.
• Endocarditis: An infection of the heart.

Living With

When should I call the doctor?

If you suspect you have a pressure injury, speak with your doctor. A pressure injury is easier to heal if it is discovered in the early stages. It is important to prevent a wound from becoming infected. Healing is delayed in an infected wound and the infection could cause problems in other areas of the body.

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Last reviewed by a Cleveland Clinic medical professional on 11/07/2018.

References

• US National Library of Medicine. National Institutes of Health. Pressure Ulcers: Current Understanding and Newer Modalities of Treatment. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413488/) Accessed 10/22/2018.
• Merck Manual. Pressure Sores. (https://www.merckmanuals.com/home/skin-disorders/pressure-sores/pressure-sores) Accessed 10/22/2018.
• National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/) Accessed 10/22/2018.

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