Pressure ulcers: What we don’t know can hurt us

Pressure ulcers have long been the bane of long-term care (LTC). Before the MDS tool even existed, nursing homes were aware of their costs and risks. Nursing homes were described as urine-smelling places where people went to die. Even good nursing homes struggled with pressure ulcer prevention and treatment. Some old “warhorses” like me remember the use of heat lamps and Betadine, lard and sugar and even painting buttocks with antacids in an attempt to heal huge wounds that we called bedsores. 

Times have certainly changed, but we still have challenges because while our knowledge has increased, the human anatomy has not changed. The risks for developing wounds will always be with us.  It is one of long-term care’s most serious challenges.

To begin to address pressure ulcer prevention, we must first define pressure ulcers. While most LTC agencies are familiar with the definitions of Stage I-IV pressure ulcers, two newer terms have been added as defined by National Pressure Ulcer Advisory Panel (NPUAP).

  • Unstageable/Unclassified: Full thickness skin or tissue loss–depth unknown. This is defined as full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
  • Suspected Deep Tissue Injury–depth unknown. This is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

What are the risks related to the development of pressure ulcers? The Advancing Excellence Campaign identifies risks including increased incontinence, decreased ability to move without help, decreased mental capacity, increased pain, increased risk for infection and less participation in activities. Other concerns include increased cost of care, increased citations related to CMS surveys, lower family satisfaction and the increased lawsuits related to substandard care.                                                                                                                                       


Now that the definitions and risks have been identified, how do we proceed to prevention? What actions would a prudent caregiver take? Since the majority of LTC caregivers are nurses, it would be appropriate to use the nursing care plan format. Identify the problem, define the goal, outline the steps to meet the goal, identify the time frame to complete steps, identify a responsible person to take the actions, assess the outcome and change protocols as necessary. Interesting how this same format matches most quality improvement format, right? 

Education is an integral step to problem solving. But just whom do we educate? All the players need to be educated and invested—nurses, nurse aides, doctors, therapists, dietitians, dietary workers, housekeeping, maintenance and families may all fall into this category. Each person may play a pivotal role in an individual’s care.

Let’s just look at a few of the more controversial caregivers. Why is housekeeping so important? Most housekeepers in long-term care know the residents, they are part of the resident’s social network and as such can do things like encourage food intake, report risky behaviors, assist with decrease of shear by monitoring residents’ sliding in bed or raise the head of bed to above 30 percent. 

Maintenance again meets the definition of a resident’s social network and may do all the things that housekeeping does. Another point we might not have considered with maintenance is the choice of beds, when equipment is delivered and wheelchair selection, maintenance and function. 

Family is another important  group to include. While they are spending time with the resident they can also encourage fluid intake, dining habits, appropriate choices and repositioning. Including the family in the care plan also assists in gaining their trust and support. This, in turn, helps to decrease complaints and lawsuits. While an educated, involved family may increase the workload at first, in the end their involvement really pays off.

No single person, department or discipline is the owner of pressure ulcer prevention. Everyone must work together for the good of the resident. 


Let us examine the education we offer these groups. Frequently decisions made at care planning are not filtered through the system. Due to confidentiality concerns, important information may not be shared. To address this and still maintain needed confidences, education is necessary. Every department in the facility that interacts with the resident in any way needs pressure ulcer prevention education. 

Direct caregivers will, of course, need extra education. Nurses need extensive education in prevention and treatment of wounds. Also, nurse aides are often the frontline defense in preventing pressure ulcers and teaching others.  As such, this important group must know not only the steps for prevention but the rationale behind the steps. An aide who does not understand how shear impacts skin integrity may take risks in turning and repositioning.  Aides might not understand which part of the meal is most important for the resident to consume. They may not place enough emphasis on fluid replacement and encourage their residents’ to drink adequate amounts. 


While we understand that prevention is important, we may not understand the full impact of this issue on our budget, our reputations and our level of care. The Agency for Healthcare Research and Quality(AHRQ) states: “Each year, more than 2.5 million people in the United States develop pressure ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care utilization.” 

No amount of education or tools, however, can replace commitment. Facility leadership must be committed to taking the necessary steps to ensure that pressure ulcer prevention is the goal of every person. Without the commitment of leadership, education will be pushed to the side by more pressing issues, equipment needs may be disregarded in pursuit of a balanced budget and attention to detail will be considered unnecessary.

There are free toolkits and education available for facilities to help decrease the financial impact of training. NPUAP’s website includes many education tools as does the AHRQ website. 

Certainly our healthcare surveyors have identified prevention of pressure ulcer development as a critical component of quality healthcare providers. Lawyers are focusing on the development of pressure ulcers as an identifier of substandard care. Advocacy groups are developing tools to identify and educate LTC providers. Isn’t it time that every facility joined ranks and pledged that this, too, will be our goal?

Sylvia J. Bennett, RN, BSN, FACDONA, is a nurse consultant at SAVE Medical. She also served as a healthcare surveyor with the Michigan Department of Health. Contact her at

Topics: Articles , Clinical , Executive Leadership , Medicare/Medicaid , Nutrition , Regulatory Compliance