Pressure Ulcers: Classification, Assessment, Prevention & Management

Question-and-answer flashcards covering definition, classification, assessment (including dark-skin considerations), risk tools, prevention strategies, patient education, and management of pressure ulcers.

What is the definition of a pressure ulcer?

A localized injury to skin and/or underlying tissue, usually over a bony prominence, caused by sustained pressure, shear or friction, and sometimes related to medical devices.

Which organisations provided the 2009 definition referenced in the notes?

EPUAP (European Pressure Ulcer Advisory Panel) & NPUAP (National Pressure Ulcer Advisory Panel).

Since 2018, what term must be used instead of “grade” for pressure ulcers?

Category (NHSi 2018).

Describe the key features of a Category I pressure ulcer.

Intact skin with non-blanchable redness (erythema); may be painful, firm, soft, warmer or cooler than adjacent tissue; harder to see in dark skin tones.

Which three-step tool helps detect Category I damage in dark skin?

Talk (ask about pain), Feel (temperature/texture), Look (compare colour to surrounding skin).

List at least four skin changes to check when assessing dark skin tones for pressure damage.

Non-blanching erythema, areas of discoloration, purple/blue or maroon hues, necrosis/black tissue, swelling, bogginess, temperature change, increased pain/itchiness.

Skin-tone bias tip #1 when assessing wounds (Black & Simende).

Obtain a history of pressure exposure (e.g., long lie after fall, prolonged surgery).

Skin-tone bias tip #2 regarding lighting.

Use good lighting—preferably natural light—and avoid fluorescents to see subtle colour changes.

Skin-tone bias tip #3 on visual comparison.

Compare the suspicious area to surrounding skin and to the opposite anatomical site.

Skin-tone bias tip #4 on palpation.

Palpate with the back of your hand to detect temperature and texture differences.

Skin-tone bias tip #5 about skin care.

Keep skin moisturised; dark-tone skin is often thicker and drier.

Describe a Category II pressure ulcer.

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, or an intact/ruptured clear serous blister; no slough or bruising.

Describe a Category III pressure ulcer.

Full-thickness skin loss; subcutaneous fat may be visible; slough may be present but does not obscure depth; bone/tendon not visible or palpable; depth varies by site.

Describe a Category IV pressure ulcer.

Full-thickness tissue loss with exposed bone, tendon or muscle; often undermining/tunnelling; slough or eschar may be present; depth varies by site.

What characterises a Deep Tissue Injury (DTI)?

Purple or maroon discoloured intact skin or blood-filled blister caused by underlying soft-tissue damage; may feel painful, firm, mushy, boggy, warmer or cooler than surrounding skin.

When is a pressure ulcer termed “unstageable”?

When full-thickness skin loss is present but the wound bed is obscured by slough or eschar, making depth impossible to determine until debrided.

How should pressure ulcers caused by medical devices be documented?

As device-related pressure ulcers (NHSi 2018).

How are pressure injuries on mucosa or areas lacking certain tissues recorded?

Document as PU (d) – ‘not possible to categorise’ (e.g., mucosa, ears, bridge of nose).

Which risk assessment tool is highlighted for pressure ulcer risk?

The Waterlow score.

How often should a patient with a Waterlow score 10–19 be repositioned?

At least every 6 hours.

How often should a patient with a Waterlow score ≥20 be repositioned?

At least every 4 hours.

What does the SSKIN bundle acronym stand for?

Surface, Skin inspection, Keep moving, Incontinence management, Nutrition/Hydration.

What repositioning technique is recommended to reduce sacral pressure?

30-degree tilt, avoiding direct positioning on existing ulcers or red areas.

Why should red areas not be massaged?

It is painful and can cause further tissue destruction.

How should heels be off-loaded in bed?

Elevate heels with pillows lengthwise so they hang free, ensuring they are not resting on the pillow surface.

State two key components of incontinence management for pressure-ulcer prevention.

Regular toileting regimen and cleansing skin with aqueous cream followed by a barrier film/cream (e.g., Medi-honey).

What nutritional advice supports pressure ulcer prevention?

Ensure adequate fluid intake and a balanced diet; use IV fluids if oral intake is restricted.

What is the main aim of providing patient and family information on pressure ulcers?

To involve them in prevention planning from admission and support concordance with care.

Name the online platform for Barts Health staff pressure-ulcer e-learning.

Barts Health Virtual Learning Platform: https://education.bartshealth.nhs.uk/moodlelive/ under ‘Multidisciplinary Training → Pressure Ulcer’.

List the five standard NPUAP/EPUAP pressure-ulcer categories in order.

Category 1, Category 2, Category 3, Category 4, Unstageable (plus Deep Tissue Injury as a separate classification).

In dark skin, what colour change may signal early deep tissue injury?

A darker area that may not appear purple/maroon but is different from surrounding skin.

What dynamic mattress system is referenced and what guides its pressure settings?

Virtuoso Series 3; pressure levels set according to patient weight ranges (0–210 kg+).

A dark red dermis colour in a wound bed may indicate what underlying issue?

Acute ischaemia.

Why is increased pain significant in early pressure damage assessment?

Pain can precede visible skin changes and signal underlying tissue injury.

What training resource should staff use for correct dressing selection and management algorithms?

Local Tissue Viability Service guidelines and dressing formulary (available on WeShare intranet).

Which five anatomical areas are high-risk for pressure ulcers in bed-bound patients?

Occiput, scapulae, sacrum, heels, and trochanters.

How should staff proceed if unsure about suspicious skin changes?

Document findings and escalate to senior team members or Tissue Viability Nurses.