Wound Care

Head
Bony
prominence
Shoulder Sacrum Heel
A pressure sore forms when pressure forces a
bony prominence to compress underlying soft tissue.
Soft tissue
In an immobile patient, pressure sores most
commonly form over bony prominences.
Supporting surface
(ex: a mattress)
External pressure
(such as gravity or bed linens)
Pressure sore
Formation of a Pressure Sore (Bedsore or Decubitus Ulcer)
Skin
layers
Subcutaneous
tissue
Skin layers are completly lost.
Necrosis of subcutaneous tissue
may extend to, but not through
the fascia.
Stages of Pressure Sores
Stage 1
Stage 2
The lesion is a reddish area which Partial thickness loss of dermis presenting as a shallow
may be hard and warm to the touch.
No skin is lost.
open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serumfilled
blister. Presents as a shiny or dry shallow
ulcer without slough or bruising.
Fascia Muscle
Stage 3
Figure 3–1 NPUAP staging system. (Redrawn from illustration Copyright © 2008 Nucleus Medical Art.
All rights reserved. www.nucleusinc.com.)
Bone
Stage 4
Necrosis reaches beyond the fascia
causing extensive damage to
support structures, such as
bone and muscle.