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Overview and Implications

A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear and or friction (IHI, n.d.; RNAO, 2011). A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated (European Pressure Ulcer Advisory Panel et al., 2019). Pressure ulcers cause considerable harm to patients, hindering functional recovery, frequently causing pain, and the development of serious infections. Pressure ulcers have also been associated with an extended length of stay, sepsis, and mortality (IHI, n.d.).

Pressure ulcers are also known as bed sores and are categorized in four stages:

Stage IThe skin is a slightly different colour, but there are no open wounds
Stage IIThe skin breaks open and an ulcer forms
Stage IIIThe sore becomes worse and creates a crater in the tissue
Stage IVThe sore is very deep causing extensive damage; these sores can harm muscle, bone, and tendons

Any stage III or stage IV pressure ulcer acquired after admission to hospital are designated as 'Never Events'. Stage III and IV ulcers can lead to serious complications such as infections of the bone or blood (sepsis) (CPSI, 2015).

Pressure ulcers (PU) continue to be a significant health concern as the population ages and the complexity of care increases across all care settings (RNAO, 2011). A literature review done in Canada in 2004 found that the overall prevalence of pressure ulcers across all institutions studied was 26 per cent. Although 50 per cent of these were Stage 1 ulcers, this data is still disturbing (Woodbury & Houghton, 2004). The total net adjusted hospitalization cost of a hospital-acquired PU in Ontario was CA $44,000 to $90,000, compared with CA $11,000 to $18,500 for a pre-admission PU (Chan et al., 2013).

Accreditation Canada has included pressure ulcer prevention as a Required Organizational Practices (ROP) in its 2020 handbook, the guidelines specify that pressure ulcer prevention strategies require an inter-disciplinary approach and support from all levels of an organization. It is useful to develop a plan to support comprehensive education on pressure ulcer prevention, and to designate individuals to facilitate the implementation of a standardized approach to risk assessments, the uptake of best practice guidelines, and the coordination of healthcare teams (Accreditation Canada, 2020).

Risk Factors

Assessment of certain categories of patients requires that the clinician be aware of
and assess for specific factors that may increase risk for skin breakdown or affect healing
of pressure injuries. Advancing age, decline of general nutritional and mental status, decreased mobility, sensory perception deficits, incontinence and the changing characteristics of the skin have been identified as a predictor of pressure-related injuries. Risk is increased for those with hypotension, contractures, or a history of cerebral vascular accident. Pressure injury incidence and prevalence rates remain higher in critical care areas due to the numbers of severely compromised patients. In the severely obese it can be challenging to assess skin and visualize all bony prominences. Surgical patients have an especially high risk of developing intra-operative pressure injuries due to the prolonged pressure from immobility during the intra-operative and immediate post-operative periods. In many terminally ill patients, multiple factors and co-morbid conditions increase their risk for the development of pressure injuries and need to be identified (Norton et al., 2018).


To reduce the incidence of new or worsening pressure ulcers in hospital.

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