Skin and nail
Pressure ulcers
Last revised in January 2024
A pressure ulcer is localized damage to skin and/or underlying tissue, due to pressure or pressure in combination with shear
Pressure ulcers: Summary
- A pressure ulcer is defined as localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. They usually occur over a bony prominence but may also be related to a medical device or other objects.
- Pressure ulcers can range in severity, from patches of discoloured skin to extensive wounds filled with necrotic tissue and involving fascia, muscle, and bone.
- Risk factors for pressure ulcers include reduced mobility, nutritional deficiency, older age, and conditions that cause inadequate blood flow to the skin and soft tissues (such as diabetes and peripheral vascular disease).
- Complications of pressure ulcers include pain, infection, and increased mortality.
- Anyone is potentially at risk of developing a pressure ulcer.
- A validated risk assessment scale, such as the Braden or PURPOSE T risk assessment tool, should be used to support clinical judgement when assessing pressure ulcer risk.
- A diagnosis of pressure ulcer is typically obvious when a person with risk factors develops evidence of skin damage over a bony prominence. Pressure damage is supported by the presence of one of the following:
- An area of non-blanchable erythema. Note that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types.
- Marked localized skin changes.
- A wound of varying severity on an anatomical site that is known (or suspected) to have previously been exposed to significant unrelieved pressure.
- Assessment of a person with a pressure ulcer includes:
- Documenting the surface area of the pressure ulcer.
- Estimating the depth of the pressure ulcer and documenting the presence of undermining.
- Categorizing the pressure ulcer using a validated classification tool. This should be used to guide ongoing preventative strategies and management.
- Investigations are not used to make the diagnosis of pressure ulcers but may be required if the diagnosis is uncertain or to exclude complications and/or differential diagnoses (such as venous ulcers, osteomyelitis, peripheral arterial disease, or malignancy). Wounds should only be swabbed if infection is suspected.
- Prevention of pressure ulcers includes:
- Offering timely, tailored information on pressure ulcers, including information on risk reduction.
- Offering a skin assessment to the person assessed as being at risk of developing a pressure ulcer.
- Developing an individualized care plan for the person, considering the outcome of the risk and skin assessments, pressure relief, the need for additional pressure relief at specific at-risk skin sites, and the person's mobility, ability to reposition, comorbidities, and preference.
- Considering the use of a barrier preparation to prevent skin damage if there are concerns with moisture or incontinence.
- Management of people with a pressure ulcer, in addition to the above, includes:
- Offering a nutritional risk assessment.
- Considering the need for pressure redistributing devices.
- Debriding the wound if indicated.
- Prescribing systemic antibiotics if indicated. The choice of antibiotic should be discussed with microbiology specialists.
- Recommending appropriate wound dressings.
Have I got the right topic?
From birth onwards.
This CKS topic covers the prevention and management of pressure ulcers.
This CKS topic does not cover the management of complications of pressure ulcers.
There are separate CKS topics on Leg ulcer - venous, Palliative care - malignant skin ulcer, and Peripheral arterial disease.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.
How up-to-date is this topic?
Changes
January 2024 — minor update. Broken link to Waterlow score updated.
Previous changes
March 2023 — this is a new CKS topic. The evidence base has been reviewed in detail, and the recommendations justified and transparently linked to supporting evidence.
Update
New evidence
Evidence-based guidelines
- DHSC (2024) Pressure ulcers: how to safeguard adults. Department of Health and Social Care. https://www.gov.uk/ [Free Full-text]
HTAs (Health Technology Assessments)
No new HTAs since 1 March 2023.
Economic Appraisals
No new economic appraisals relevant to England since 1 March 2023.
Systematic reviews and meta-analyses
No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2023.
Primary evidence
No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2023.
New policies
No new national policies or guidelines since 1 March 2023.
New safety alerts
No new safety alerts since 1 March 2023.
Changes in product availability
No changes in product availability since 1 March 2023.
Goals and outcome measures
Goals
To support primary health care professionals to:
- Assess a person's risk of developing pressure ulcers.
- Prevent pressure ulcers.
- Make a diagnosis of pressure ulcers.
- Assess the severity of pressure ulcers.
- Offer appropriate management in primary care.
- Refer to other healthcare professionals when appropriate.
Outcome measures
No outcome measures were found during the review of this topic.
Audit criteria
No audit criteria were found during the review of this topic.
QOF indicators
No QOF indicators were found during the review of this topic.
NICE quality standards
- Statement 1. People admitted to hospital or a care home with nursing have a pressure ulcer risk assessment within 6 hours of admission.
- Statement 2. People with a risk factor for developing pressure ulcers who are referred to community nursing services have a pressure ulcer risk assessment at the first face-to-face visit.
- Statement 3. People have their risk of developing pressure ulcers reassessed after a surgical or interventional procedure, or after a change in their care environment following a transfer.
- Statement 4. People have a skin assessment if they are identified as high risk of developing pressure ulcers.
- Statement 5. People at risk of developing pressure ulcers receive advice on the benefits and frequency of repositioning.
- Statement 6. People at risk of developing pressure ulcers, who are unable to reposition themselves, are helped to change their position.
- Statement 7. People at high risk of developing pressure ulcers, and their carers, receive information on how to prevent them.
- Statement 8. People at high risk of developing pressure ulcers are provided with pressure redistribution devices.
QIPP — Options for local implementation
No QIPP indicators were found during the review of this topic.
Background information
What is a pressure ulcer?
- A pressure ulcer is defined as localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. They usually occur over a bony prominence but may also be related to a medical device or other objects.
- Pressure ulcers can range in severity, from patches of discoloured skin to extensive wounds filled with necrotic tissue and involving fascia, muscle, and bone.
- Pressure ulcers most commonly occur over bony prominences but can develop on any part of the body, including mucosal surfaces.
What are the causes of pressure ulcers?
- Pressure ulcers are caused by pressure, or pressure in combination with shear forces [EPUAP/NPIAP/PPPIA, 2019; Gefen, 2020; BMJ, Best Practice 2021; OHID, 2022].
- The duration and intensity of pressure are important: tissue damage may occur as a result of relatively short exposures to intense pressure or prolonged exposure to lower levels of pressure. Pressure forces are distributed throughout the soft tissue, the extent depending on the mechanical properties of both the soft tissues and any external support surface or device.
- Shear forces, typically generated when people slide down in a bed or chair, may cause stretching and tearing of small blood vessels and contribute to pressure-induced skin damage.
- Friction and moisture can also contribute to the development of pressure ulcers:
- Friction can cause superficial injuries, including skin tears, which could facilitate the transmission of pressure to the deeper tissues.
- Moisture decreases the stiffness of the stratum corneum and increases the coefficient of friction so that skin is more adherent to the contact surface, resulting in greater shear forces being transmitted to deeper tissues. Additionally, moisture can cause moisture-associated dermatitis, which could also facilitate the transmission of pressure to the deeper tissues.
- Pressure ulcers can occur due to the forces of a person’s body weight or as a result of externally exerted forces, such as those applied by a medical device and/or other objects [EPUAP/NPIAP/PPPIA, 2019; Gefen, 2020].
- When a person is immobilized for extended periods, for example, in the supine position, the pressure and shear forces cause tissue deformation, inflammatory oedema, and ischaemia, leading to pressure ulceration in bony anatomical sites, such as the sacrum, ischium, elbows, and heels.
- Medical device-related pressure ulcers result from the use of devices designed and applied for diagnostic or therapeutic purposes (such as continuous positive airway pressure masks, nasogastric tubes, cervical collars, or splints) [NPIAP, 2016]. Localized forces from the device deform/damage the underlying skin and soft tissues, and the resultant pressure ulcer generally conforms to the pattern or shape of the device. Non-medical devices (such as bed clutter and furniture) can also result in pressure ulcers when they remain in contact with skin and tissues.
- The tolerance of soft tissue for sustained deformations differs by tissue type and may also be affected by age, health status, microclimate, comorbidities, and conditions of the soft tissues. People with conditions that cause inadequate blood flow to the skin and soft tissues (such as peripheral vascular disease, heart failure, diabetes, and sepsis) are at increased risk of developing pressure ulcers.
What are the risk factors for pressure ulcers?
- Anyone is potentially at risk of developing a pressure ulcer. However, they are more likely to occur in the presence of the following risk factors:
- Significantly limited mobility, for example, due to spinal cord injury.
- Significant loss of sensation, for example, due to neurological impairment.
- Significant cognitive impairment.
- Poor posture and/or deformity.
- Inability to independently reposition.
- Nutritional deficiency.
- A previous or current pressure ulcer.
- General skin status and skin moisture [Coleman, 2014].
- Conditions that cause inadequate blood flow to the skin and soft tissues, for example, hypotension, diabetes, heart failure, and peripheral vascular disease.
- Older age, largely due to age-related problems, such as hip fractures, incontinence, dry skin, chronic systemic conditions, and terminal illness.
- Regular use of non-pressure-relieving support surfaces, such as chairs or beds, that are not specifically designed to provide pressure relief.
- Regular use of medical or other devices.
[EPUAP/NPIAP/PPPIA, 2019; BMJ, Best Practice 2021; NICE, 2022a; OHID, 2022]
How common are pressure ulcers?
- Worldwide, the incidence of pressure ulcers in healthcare settings ranges from 0–72%, with large variations observed between different geographic and clinical settings [EPUAP/NPIAP/PPPIA, 2019].
- In the UK, over 700,000 people are affected by pressure ulcers each year. Of these, 180,000 are newly acquired each year [Wood, 2019].
- In a cross-sectional observational study on the prevalence of pressure ulcers in two community settings in the North of England [Stevenson, 2013]:
- 185 people were assessed as having a grade 1 or higher pressure ulcer in community setting 1 (prevalence rate of 0.77 per 1000 adults).
- 102 people were assessed as having a grade 1 or higher pressure ulcer in community setting 2 (prevalence rate of 0.40 per 1000 adults).
- In a cross-sectional observational study on the prevalence of pressure ulcers in two community settings in the North of England [Stevenson, 2013]:
- The incidence and prevalence of pressure ulcers increase with age [BMJ, Best Practice 2021; OHID, 2022].
- Over 60% of ulcers occur in people aged over 70 years of age. It is unclear whether this is due to age-related skin changes or the fact that conditions causing immobility are more common in older people [BMJ, Best Practice 2021].
What is the prognosis?
- The prognosis of a pressure ulcer is determined by the severity of the wound and the presence of ongoing risk factors.
- In people with superficial damage, the prognosis is reasonable if appropriate local wound care is provided [BMJ, Best Practice 2021].
- In seriously ill people with extensive ulcers, the prognosis is poor, especially because they may be unable to tolerate or accept the intensive treatment required to close their wound surgically [BMJ, Best Practice 2021].
- A prospective cohort study of prognostic factors for the healing of heel pressure ulcers found that increased ulcer severity and the presence of peripheral arterial disease significantly reduced the probability of wound healing [McGinnis, 2014a].
What are the complications?
- Complications of pressure ulcers include:
- Pain and distress [Briggs, 2013; McGinnis, 2014b].
- Infection (for example cellulitis or osteomyelitis), which can lead to systemic infection or sepsis [BMJ, Best Practice 2021].
- Longer hospital stays (an average of 5–8 days per pressure ulcer) [Graves, 2005; Theisen, 2012; Wood, 2019].
- Increased mortality and morbidity [McGinnis, 2014a; OHID, 2022].
- Reduced quality of life [Gorecki, 2009; Gorecki, 2012].
- Pressure ulcers are costly to healthcare providers: treating pressure ulcers costs the NHS over £1.4 million every day [NHS England, 2019; OHID, 2022].
Diagnosis
How should I assess a person's risk of developing a pressure ulcer?
- Anyone is potentially at risk of developing a pressure ulcer.
- Carry out an assessment of pressure ulcer risk for:
- All people being admitted to secondary care or to care homes in which NHS care is provided.
- All people receiving NHS care in other settings (such as primary and community care, and emergency departments) if they have a risk factor for developing pressure ulcers, such as significantly limited mobility or neurological impairment.
- Consider carrying out an assessment of pressure ulcer risk for all people in their own homes or in social/nursing care settings.
- Carry out an assessment of pressure ulcer risk for:
- Consider using a validated risk assessment scale to support clinical judgement when assessing pressure ulcer risk.
- The recommended risk assessment scales include:
- For adults: Braden Risk Assessment tool, Waterlow score, Norton risk assessment scale, or the PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool).
- For children: the Braden Q Scale.
- People are considered to be:
- At risk of developing a pressure ulcer if they are deemed to be at risk based on clinical judgement and/or the use of a risk assessment tool.
- At high risk of developing a pressure ulcer if multiple risk factors (for example significantly limited mobility, nutritional deficiency, inability to reposition themselves, or significant cognitive impairment) are identified during the risk assessment, with or without a validated risk assessment tool. People with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
- The recommended risk assessment scales include:
- Document the findings of the risk assessment.
- Reassess pressure ulcer risk, particularly if there is a change in clinical status (for example after surgery, on worsening of an underlying condition, or with a change in mobility).
Basis for recommendation
These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Pressure ulcers: prevention and management [NICE, 2022a]. NICE reviewed the guideline in 2018, and although new evidence was found, it did not warrant a change in recommendations.
When to carry out a risk assessment
- NICE recommends that [NICE, 2022a]:
- An assessment of pressure ulcer risk should be carried out and documented for:
- All people being admitted to secondary care or care homes in which NHS care is provided.
- All people receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor for developing pressure ulcers.
- Pressure ulcer risk should be reassessed if there is a change in clinical status (for example after surgery, on worsening of an underlying condition, or with a change in mobility).
- An assessment of pressure ulcer risk should be carried out and documented for:
- As part of the 2018 guideline review, the NICE committee requested feedback from topic experts, who either participated in the guideline development committee or were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty.
- The topic experts raised several issues, including that 'Risk assessments should be carried out in all care homes (not just where residents are receiving NHS care), and on all patients in NHS settings (not just if they have a risk factor). And a review of risk should be routine (not just after a change in clinical status)'.
- NICE found no evidence to support changes to the recommendations in that area.
- An expert reviewer of this CKS topic recommends that an assessment of pressure ulcer risk should be considered for all people in their own homes or in social/nursing care settings and the assessment should be ongoing. CKS considers this to be a pragmatic recommendation.
Risk assessment tools
- NICE recommends considering using a validated scale, such as the Braden scale, the Waterlow score, the Norton risk assessment scale, or the Braden Q scale (for children), when assessing pressure ulcer risk.
- The National Wound Care Strategy Programme (NWCSP) recommends the PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) for use in adults. The PURPOSE-T identifies adults at risk of developing a pressure ulcer and supports nurse decision‐making to reduce that risk (primary prevention). It also identifies people with existing and previous pressure ulcers requiring secondary prevention and treatment.
How should I diagnose and assess a person with a pressure ulcer?
Pressure ulcers should be diagnosed and assessed by healthcare professionals with the necessary skills and competencies.
- Diagnose a pressure ulcer if a person with risk factors develops evidence of skin damage over a bony prominence.
- The diagnosis of a pressure ulcer is supported by the presence of one of the following:
- An area of non-blanchable erythema. Be aware that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types.
- Marked localized skin changes.
- A wound of varying severity on an anatomical site that is known (or suspected) to have previously been exposed to significant unrelieved pressure.
- The diagnosis of a pressure ulcer is supported by the presence of one of the following:
- Document:
- The surface area of the pressure ulcer, preferably using a validated measurement technique (such as a photograph).
- An estimate of the depth of the pressure ulcer and the presence of undermining. Do not routinely measure the volume of a pressure ulcer.
- Categorize the pressure ulcer using a validated classification tool, such as the NPUAP–EPUAP Pressure Ulcer Classification System (published by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel).
- The NPUAP-EPUAP system classifies pressure ulcers into 6 categories/stages:
- Category/Stage I: nonblanchable erythema.
- Category/Stage II: partial thickness skin loss.
- Category/Stage III: full-thickness skin loss.
- Category/Stage IV: full-thickness tissue loss.
- Unstageable: depth unknown.
- Suspected deep tissue injury: depth unknown.
- Use the classification to guide ongoing preventative strategies and management.
- Repeat and document the classification each time the ulcer is assessed.
- The NPUAP-EPUAP system classifies pressure ulcers into 6 categories/stages:
- Investigations are not used to make the diagnosis of pressure ulcers.
- However, they may be required if the diagnosis is uncertain or to exclude complications and/or differential diagnoses of pressure ulcers.
- Wounds should only be swabbed if infection is suspected.
- Consider or suspect abuse or neglect (particularly malnourishment, lack of repositioning, or poor continence management) as a contributory factor to (or cause of) pressure ulcers in children and adults.
- Child abuse is common, can present in all care settings (including in the child's home), and may coexist with pressure ulcers. See the CKS topic on Child maltreatment - recognition and management for information on clinical features that may be associated with child maltreatment.
- The Department of Health and Social Care has issued a protocol for safeguarding adults at risk of pressure ulcers, which aims to help practitioners and managers across health and care organizations to provide caring and quick responses to people at risk of developing pressure ulcers.
Basis for recommendation
These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Pressure ulcers: prevention and management [NICE, 2022a] and on expert opinion in a review article [BMJ, Best Practice 2021].
NICE reviewed the guideline in 2018, and although new evidence was found, it did not warrant a change in recommendations. The recommendations are in line with the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline published by the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA) [EPUAP/NPIAP/PPPIA, 2019].
Diagnosis of a pressure ulcer
- The information on the physical appearance of pressure ulcers is based on expert opinion in a review article [BMJ, Best Practice 2021].
- NICE advises that healthcare professionals should be aware that non-blanchable erythema may present as colour changes or discolouration, particularly in people with darker skin tones or types [NICE, 2022a].
Wound swabbing
- A wound containing quantities of necrotic tissue or slough will most likely contain bacteria, such as Staphylococcus aureus, Proteus mirabilis, and Pseudomonas aeruginosa. Swabbing such a wound will usually detect large numbers of organisms, which may initiate unnecessary treatment with antibiotics. Therefore, wounds should only be swabbed if infection is suspected, and should not be swabbed routinely [EPUAP/NPIAP/PPPIA, 2019; BMJ, Best Practice 2021].
Investigations
- Diagnostic tests are not used to make the diagnosis of pressure ulcers. However, certain tests may help in diagnosing complications of pressure ulcers, including wound infection and osteomyelitis [BMJ, Best Practice 2021].
What are the differential diagnoses of pressure ulcers?
- Differential diagnoses of pressure ulcers include:
- Diabetic foot ulcer.
- Moisture lesions.
- Osteomyelitis.
- Dermatological lesions, such as pyoderma gangrenosum and bullous pemphigoid.
- Malignancy. For more information, see the CKS topic on Skin cancers - recognition and referral.
- Peripheral arterial disease. For more information, see the CKS topic on Peripheral arterial disease.
- Venous ulcers. For more information, see the CKS topic on Leg ulcer - venous.
Basis for recommendation
The information on differential diagnoses is based on expert opinion in a review article [BMJ, Best Practice 2021] and on the expert opinion of reviewers of this CKS topic.
Management
Scenario: Prevention of pressure ulcers
From birth onwards.
How should I prevent pressure ulcers in adults?
Adults assessed as being at risk of pressure ulcers should be managed by healthcare professionals with the necessary skills and competencies.
- Offer appropriate information on pressure ulcers.
- This should include information on the causes, risk factors, prognosis, possible complications, and early signs of a pressure ulcer.
- The NHS website has patient information on Pressure ulcers (pressure sores).
- Take into account individual needs when giving information to people with:
- Degenerative conditions.
- Impaired mobility.
- Neurological impairment.
- Cognitive impairment.
- Impaired tissue perfusion, for example, caused by peripheral arterial disease.
- This should include information on the causes, risk factors, prognosis, possible complications, and early signs of a pressure ulcer.
- Offer a skin assessment by a trained healthcare professional.
- This should consider any pain or discomfort reported by the person, and the skin should be checked for:
- Skin integrity in areas of pressure.
- Colour changes or discolouration. Be aware that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types.
- Variations in heat, firmness, and moisture (for example due to incontinence, oedema, and dry or inflamed skin).
- This should consider any pain or discomfort reported by the person, and the skin should be checked for:
- Develop and document an individualized care plan.
- Take into account:
- The outcome of the risk assessment.
- The outcome of the skin assessment.
- Other comorbidities.
- The person's preferences.
- Consider the person's mobility and their ability to reposition themself.
- Encourage the person to change their position at least every 6 hours if they have been assessed as being at risk of developing a pressure ulcer, or at least every 4 hours if assessed as being at high risk of developing a pressure ulcer.
- If they are unable to reposition themselves, they should be offered help to do so, using appropriate equipment if needed.
- Consider the need for pressure relief, including additional pressure relief at specific at-risk body sites (such as the heel).
- Recommend a high-specification foam mattress for people assessed as being at high risk of developing pressure ulcers.
- Consider the seating needs of people who are sitting for prolonged periods. Consider a high-specification foam or equivalent pressure redistributing cushion for people who use a wheelchair or who sit for prolonged periods.
- If the person is at high risk of developing a heel pressure ulcer, discuss (and document) a strategy to offload heel pressure.
- Take into account:
- Consider prescribing a barrier preparation to prevent skin damage in people who are at high risk of developing a moisture lesion or incontinence-associated dermatitis (such as those with incontinence or oedema).
- If the skin is dry or inflamed, an emollient should be used.
- Do not offer:
- Skin massage or rubbing to prevent pressure ulcers.
- Subcutaneous or intravenous fluids specifically to prevent pressure ulcers in adults whose hydration status is adequate.
- Nutritional supplements specifically to prevent pressure ulcers in adults whose nutritional intake is adequate. The National Institute for Health and Care Excellence guideline on Nutrition support for adults contains details of nutrition support other than supplements, and advice on energy and protein intake levels.
Heel pressure ulcers
- The heel is a common site for pressure ulcers to develop [Greenwood, 2022].
- Many interventions aim to reduce either the intensity or the duration of pressure, or the friction or sheer forces.
- Heel-specific pressure-reducing devices can be categorized as [Greenwood, 2022]:
- Constant low-pressure (CLP) devices, such as gel or foam heel pads/cups and booties, that aim to distribute the pressure over a larger surface area.
- Offloading devices, such as pillows, wedges, or splints, that prevent contact between the heel and the bed.
- Low friction devices, such as dressings or booties, that reduce friction and sheer when the person moves their foot.
- Devices with combinations of functions, for example, prophylactic dressing or devices that reduce pressure and/or friction and shear, such as multilayer heel dressings and medical-grade sheepskin.
- The National Institute for Health and Care Excellence (NICE) guideline on Diabetic foot problems: prevention and management has advice on heel pressure offloading.
- A clinical guideline by the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA) makes the following recommendations [EPUAP/NPIAP/PPPIA, 2019]:
- Assess the vascular/perfusion status of the lower limbs, heels, and feet when performing a skin and tissue assessment, and as part of a risk assessment.
- For individuals at risk of heel pressure injuries and/or with Category/Stage I or II pressure injuries:
- Elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion.
- Offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein.
- For individuals with a Category/Stage III or greater heel pressure injury:
- Elevate the heels using a specifically designed heel suspension device, offloading the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein.
- Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries.
- Parafricta® garments (Bootees and Undergarments) are designed specifically to reduce friction and associated shear, thereby reducing the potential for pressure ulcer and friction lesion development. Bootees protect the heel and ankle; Undergarments protect the sacrum, buttocks, and hips [Parafricta, 2015].
- The NICE medical technology guidance Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers concluded that although the garments are a promising technology, with the potential to reduce skin damage and the incidence and severity of pressure ulcers in both hospitals and the community, more evidence about their clinical benefits is needed to support the case for more widespread, routine adoption [NICE, 2022b].
- A systematic review (n = 4724) compared the effectiveness of heel-specific medical devices for the prevention of heel pressure ulcers [Greenwood, 2022].
- Comparisons between heel-specific offloading devices and standard care found a significant benefit of the device for all categories of heel pressure ulcers. The overall quality of the evidence was low. However, when one of the trials was excluded, the evidence was assessed as moderate quality.
- Comparisons between prophylactic dressings (such as multilayer heel dressings) and standard care showed no significant difference in effectiveness of prophylactic dressings.
- Comparisons between two different heel-specific offloading devices showed no clear difference in heel pressure ulcer incidence.
- In a paediatric post-surgical population, comparisons between a heel-specific offloading device and standard care showed no clear difference in heel pressure ulcer incidence. Comparisons between dressings (CLP device) and standard care showed no clear difference in heel pressure incidence.
Basis for recommendation
These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Pressure ulcers: prevention and management [NICE, 2022a]. NICE reviewed the guideline in 2018, and although new evidence was found, it did not warrant a change in recommendations.
How should I prevent pressure ulcers in children and young people?
Children and young people assessed as being at risk of pressure ulcers should be managed by healthcare professionals with the necessary skills and competencies.
- Offer appropriate information to the child or young person and/or their family or carers.
- This should include information on the causes, risk factors, prognosis, possible complications, and early signs of a pressure ulcer.
- The NHS website has patient information on Pressure ulcers (pressure sores).
- Take into account individual needs when giving information to children and young people with:
- Degenerative conditions.
- Impaired mobility.
- Neurological impairment.
- Cognitive impairment.
- Impaired tissue perfusion, for example, caused by peripheral arterial disease.
- This should include information on the causes, risk factors, prognosis, possible complications, and early signs of a pressure ulcer.
- Offer a skin assessment by a trained healthcare professional.
- This should consider any pain or discomfort reported by the child or young person, and the skin should be checked for:
- Skin changes, including in the occipital area where children and young people are at risk of developing pressure ulcers.
- Skin temperature.
- The presence of blanching erythema or discoloured areas of skin. Be aware that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types.
- This should consider any pain or discomfort reported by the child or young person, and the skin should be checked for:
- Develop and document an individualized care plan.
- Take into account:
- The outcome of the risk assessment.
- The outcome of the skin assessment.
- Other comorbidities.
- The preferences of the child or young person and/or their family/carers.
- Consider the child or young person's mobility and their ability to reposition themself.
- Advise that the child or young person should change their position at least every 4 hours if they have been assessed as being at risk of developing a pressure ulcer, or more frequently than every 4 hours if assessed as being at high risk of developing a pressure ulcer.
- If they are unable to reposition themselves, they should be offered help to do so, using appropriate equipment if needed. Ensure that repositioning equipment is available to aid the repositioning of children and young people, if needed.
- Ensure that the child or young person and/or their parents/carers understand the reasons for repositioning. If the child or young person declines repositioning, document and discuss their reasons for declining.
- Consider involving a play expert to encourage children who have difficulty with, or who have declined, repositioning.
- Advise that pressure on the scalp and head should be relieved when repositioning children and young people who are at risk of developing a pressure ulcer.
- Consider the need for pressure relief, including additional pressure relief at specific at-risk body sites (such as the heel).
- Recommend a high-specification foam cot mattress, foam mattress, or overlay (as appropriate) for children and young people who are assessed as being at high risk of developing a pressure ulcer.
- Offer children and young people who are long-term wheelchair users regular wheelchair assessments, and provide pressure relief or redistribution.
- Offer children and young people at risk of developing an occipital pressure ulcer an appropriate pressure redistributing surface, for example, a suitable pillow or pressure redistributing pad.
- If the child or young person is at high risk of developing a heel pressure ulcer, discuss a strategy to offload heel pressure.
- Take into account:
- Consider prescribing a barrier preparation to prevent skin damage in children and young people who are at high risk of developing a moisture lesion or incontinence-associated dermatitis (such as those with incontinence or oedema).
- If the skin is dry or inflamed, an emollient should be used.
- Do not offer:
- Skin massage or rubbing to prevent pressure ulcers.
- Subcutaneous or intravenous fluids specifically to prevent pressure ulcers in children and young people whose hydration status is adequate.
- Nutritional supplements specifically to prevent pressure ulcers in children and young people whose nutritional intake is adequate.
Basis for recommendation
These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Pressure ulcers: prevention and management [NICE, 2022a]. NICE reviewed the guideline in 2018, and although new evidence was found, it did not warrant a change in recommendations.
Scenario: Management of pressure ulcers
From birth onwards.
How should I manage an adult with a pressure ulcer?
Adults with pressure ulcers should be assessed and managed by healthcare professionals with the necessary skills and competencies.
In addition to the recommendations for prevention:
- Perform a nutritional risk assessment.
- If the person is assessed as being at risk of nutritional deficiency, refer to a dietitian to provide:
- Advice on how to follow a balanced diet to maintain an adequate nutritional status, taking into account energy, protein, and micronutrient requirements.
- Nutritional supplements (for people with nutritional deficiencies).
- Do not offer:
- Nutritional supplements to treat pressure ulcers in adults whose nutritional intake is adequate.
- Subcutaneous or intravenous fluids to treat pressure ulcers in adults whose hydration status is adequate.
- The National Institute for Health and Care Excellence guideline on Nutrition support for adults contains details on nutrition support other than supplements, and advice on energy and protein intake levels.
- If the person is assessed as being at risk of nutritional deficiency, refer to a dietitian to provide:
- Consider the need for pressure redistributing devices.
- Recommend high-specification foam mattresses for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface. A standard-specification foam mattress should not be used for adults with pressure ulcers.
- Consider the seating needs of adults who have pressure ulcers and are sitting for prolonged periods.
- Consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or sit for prolonged periods and who have pressure ulcers.
- Assess the need for wound debridement.
- Consider:
- The amount of necrotic tissue.
- The category, size, and extent of the pressure ulcer.
- The person's tolerance level.
- The impact of the wound on the person's quality of life (for example odour and exudate).
- Any comorbidities.
- Risk of infection.
- The skill level of the practitioner.
- If debridement is indicated:
- Autolytic debridement should be used, with an appropriate dressing to support it.
- Sharp debridement should be considered if autolytic debridement is likely to take longer and prolong healing time, and should only be performed by a trained and competent practitioner.
- Enzymatic debridement should not be routinely offered.
- Larval (maggot) therapy should not be routinely offered. However, it can be considered if sharp debridement is contraindicated or if there is associated vascular insufficiency.
- Consider:
- Consider the need for antibiotic treatment.
- Offer systemic antibiotics only if there is clinical evidence of systemic sepsis, spreading cellulitis, or underlying osteomyelitis. For more information, see the CKS topic on Cellulitis - acute.
- Discuss with microbiology to ensure that the chosen systemic antibiotic is effective against specific local pathogens.
- Do not offer systemic antibiotics:
- Specifically to heal a pressure ulcer.
- Based only on positive wound cultures, without clinical evidence of infection.
- Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer.
- Recommend an appropriate wound dressing.
- The choice of dressing should take into account:
- The person's pain and tolerance level.
- The position of the ulcer.
- The amount of exudate.
- Frequency of dressing change.
- Consider using a dressing that promotes a warm, moist, wound-healing environment to treat Category II, III, and IV pressure ulcers.
- Do not offer gauze dressings to treat a pressure ulcer.
- For detailed information on wound dressings, see the section on Wound management products and elasticated garments in the British National Formulary (BNF).
- The choice of dressing should take into account:
- Provide sources of additional information and support.
- The NHS website has information on Pressure ulcers (pressure sores).
- The National Wound Care Strategy Programme (NWCSP) website has information on Looking After Your Wound and a demonstration video on wound dressing.
- Do not:
- Offer electrotherapy or hyperbaric oxygen therapy to treat pressure ulcers.
- Routinely offer negative pressure wound therapy to treat pressure ulcers, unless it is necessary to reduce the number of dressing changes (for example in a wound with a large amount of exudate).
Basis for recommendation
These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Pressure ulcers: prevention and management [NICE, 2022a]. NICE reviewed the guideline in 2018, and although new evidence was found, it did not warrant a change in recommendations.
Nutritional assessment
- The recommendation to perform a nutritional risk assessment first, then refer to a dietitian if the person is assessed as being at high risk of nutritional deficiency, is based on the expert opinion of a reviewer of this CKS topic.
- NICE recommends offering adults with pressure ulcers a nutritional assessment by a dietitian or other healthcare professional with the necessary skills and competencies [NICE, 2022a]. However, the reviewer pointed out that it is very unlikely that a dietitian would assess a person just because they have a pressure ulcer unless they have been assessed as being at high risk of nutritional deficiency.
High-specification foam mattresses
- A multicentre, Phase III, open, prospective randomized controlled trial (PRESSURE 2 trial) assessed the time taken to develop a new pressure ulcer of Category II or more in people using an alternating pressure mattress (APM, n=1016) compared with a high-specification foam mattress (HSFM, n = 1013) [Nixon, 2019].
- A total of 132 people developed at least one new pressure ulcer of Category II or more before the end of treatment (60 days maximum). Of these, 53 people were allocated to the APM arm and 79 to the HSFM arm, a difference of 2.6%.
- Nurses looked at participants’ skin again 30 days after the person had stopped using a trial mattress. At this point, 160 people had at least one new pressure ulcer (Category II or more). Of these, 70 people were allocated to the APM arm and 90 to the HSFM arm, a difference of 2%. More people in the APM group asked to change mattresses.
- The study focused on people at high-risk of developing pressure ulcers; however, only a small number of people developed pressure ulcers, suggesting that prevention is possible with either mattress. Results also suggest that certain groups of people may benefit more from APMs, for example, people who cannot give consent or who have skin redness.
- The authors concluded that decisions should take into account skin status, the person's preferences (movement ability and rehabilitation needs), and the presence of factors that may be potentially modifiable through the allocation of alternating pressure mattress, including being completely immobile, having nutritional deficits, lacking capacity, and/or having altered skin/Category I pressure ulcer.
- A Cochrane systematic review (search date: July 2020) identified a Cochrane Review reporting the effectiveness of beds, mattresses, or overlays for preventing or treating pressure ulcers [Shi, 2021].
- The evidence showed that:
- Compared with foam surfaces, reactive air surfaces may reduce pressure ulcer risk and may increase complete ulcer healing.
- Compared with foam surfaces, alternating pressure air surfaces may reduce pressure ulcer risk and are probably more cost‐effective in preventing pressure ulcers.
- Compared with foam surfaces, reactive gel surfaces may reduce pressure ulcer risk, particularly for people in operating rooms and long‐term care settings.
- There are uncertainties regarding the relative effectiveness of other support surfaces for preventing and treating pressure ulcers, and their efficacy ranking.
- The authors concluded that more high‐quality research is required. For example, for the comparison of reactive air surfaces with alternating pressure air surfaces. Future studies should consider time‐to‐event outcomes and be designed to minimize any risk of bias.
- The evidence showed that:
How should I manage a child or young person with a pressure ulcer?
Children and young people with pressure ulcers should be assessed and managed by healthcare professionals with the necessary skills and competencies.
In addition to the recommendations for prevention:
- Perform an age-related nutritional risk assessment to assess the risk of nutritional deficiency.
- If the child or young person is assessed as being at risk of nutritional deficiency, refer to a paediatric dietitian (or other healthcare professional with the necessary skills and competencies) to:
- Advise on the need for nutritional supplements specifically to treat pressure ulcers when nutritional intake is adequate.
- Advise on nutritional supplements to correct nutritional deficiencies.
- Assess fluid balance in the child or young person.
- Advise on adequate nutrition and hydration for age, growth, and healing.
- If the child or young person is assessed as being at risk of nutritional deficiency, refer to a paediatric dietitian (or other healthcare professional with the necessary skills and competencies) to:
- Consider the need for pressure redistributing devices.
- Consider using specialist support surfaces (including dynamic support surfaces where appropriate) for children and young people with a pressure ulcer, taking into account their current pressure ulcer risk and mobility.
- Use a high-specification cot mattress, bed mattress, or overlay (as appropriate) for children and young people with pressure ulcers.
- If pressure on the affected area cannot be adequately relieved by other means (such as repositioning), consider a dynamic support surface, appropriate to the size and weight of the child or young person, if this can be tolerated.
- Tailor the support surface to the location and cause of the pressure ulcer.
- Assess the need for wound debridement.
- Consider autolytic debridement with appropriate dressings for dead tissue.
- Consider sharp and surgical debridement by trained staff if autolytic debridement is unsuccessful.
- Consider the need for antibiotic treatment.
- Consider systemic antibiotics if there is clinical evidence of local or systemic infection. For more information, see the CKS topic on Cellulitis - acute.
- Discuss with microbiology to ensure that the chosen systemic antibiotic is effective against specific local pathogens.
- Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer.
- Recommend an appropriate dressing.
- Consider using a dressing that promotes a warm, moist, wound-healing environment to treat Category II, III, and IV pressure ulcers.
- Consider using topical antimicrobial dressings to treat a pressure ulcer where clinically indicated, for example, where there is spreading cellulitis.
- Do not:
- Offer gauze dressings to treat a pressure ulcer.
- Use iodine dressings to treat a pressure ulcer in neonates.
- For detailed information on wound dressings, see the section on Wound management products and elasticated garments in the British National Formulary (BNF).
- Provide sources of additional information and support.
- The NHS website has information on Pressure ulcers (pressure sores).
- The National Wound Care Strategy Programme (NWCSP) website has information on Looking After Your Wound and a demonstration video on wound dressing.
- Do not:
- Routinely use negative pressure wound therapy to treat pressure ulcers in children and young people.
- Use electrotherapy or hyperbaric oxygen therapy to treat pressure ulcers.
Basis for recommendation
These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Pressure ulcers: prevention and management [NICE, 2022a]. NICE reviewed the guideline in 2018, and although new evidence was found, it did not warrant a change in recommendations.
Nutritional assessment
- The recommendation to perform a nutritional risk assessment first, then refer to a dietitian if the child or young person is assessed as being at high risk of nutritional deficiency is based on the expert opinion of a reviewer of this CKS topic.
- NICE recommends offering an age-related nutritional assessment to a child or young person with a pressure ulcer, performed by a paediatric dietitian or other healthcare professional with the necessary skills and competencies [NICE, 2022a]. However, the reviewer pointed out that it is very unlikely that a dietitian would assess a person just because they have a pressure ulcer unless they have been assessed as being at high risk of nutritional deficiency.
Supporting evidence
This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Pressure ulcers: prevention and management [NICE, 2022a]. NICE reviewed the guideline in 2018, and although new evidence was found, it did not warrant a change in recommendations.
The recommendations are in line with the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline published by the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA) [EPUAP/NPIAP/PPPIA, 2019].
How this topic was developed
This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of pressure ulcers.
Search dates
Unrestricted - October 2022
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.
- Exp pressure ulcer/ (ulcer ADJ pressure).tw
Sources of guidelines
- National Institute for Health and Care Excellence (NICE)
- Scottish Intercollegiate Guidelines Network (SIGN)
- Royal College of Physicians
- Royal College of General Practitioners
- Royal College of Nursing
- NICE Evidence
- Health Protection Agency
- World Health Organization
- National Guidelines Clearinghouse
- Guidelines International Network
- TRIP database
- GAIN
- NHS Scotland National Patient Pathways
- New Zealand Guidelines Group
- Agency for Healthcare Research and Quality
- National Health and Medical Research Council (Australia)
- Royal Australian College of General Practitioners
- British Columbia Medical Association
- Canadian Medical Association
- Alberta Medical Association
- University of Michigan Medical School
- Michigan Quality Improvement Consortium
- Singapore Ministry of Health
- National Resource for Infection Control
- Patient UK Guideline links
- UK Ambulance Service Clinical Practice Guidelines
- RefHELP NHS Lothian Referral Guidelines
- Medline (with guideline filter)
- Driver and Vehicle Licensing Agency
- NHS Health at Work(occupational health practice)
Sources of systematic reviews and meta-analyses
- The Cochrane Library:
- Systematic reviews
- Protocols
- Database of Abstracts of Reviews of Effects
- Medline (with systematic review filter)
- EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
- NIHR Health Technology Assessment programme
- The Cochrane Library:
- NHS Economic Evaluations
- Health Technology Assessments
- Canadian Agency for Drugs and Technologies in Health
- International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
- The Cochrane Library:
- Central Register of Controlled Trials
- Medline (with randomized controlled trial filter)
- EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Sources of national policy
- Department of Health
- Health Management Information Consortium(HMIC)
Patient experiences
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
Stakeholder engagement
Our policy
The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:
- Clinical accuracy.
- Consistency with other providers of clinical knowledge for primary care.
- Accuracy of implementation of national guidance (in particular NICE guidelines).
- Usability.
Principles of the consultation process
- The process is inclusive and any individual may participate.
- To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
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- Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
- External reviewers are not paid for commenting on the draft topics.
- Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
- All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
- All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.
Stakeholders
- Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
- Stakeholders identified from the following groups are invited to review draft topics:
- Experts in the topic area.
- Professional organizations and societies (for example, Royal Colleges).
- Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
- Guideline development groups where the topic is an implementation of a guideline.
- The British National Formulary team.
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Patient engagement
Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:
- Topic selection
- Scoping of topic
- Selection of clinical scenarios
- First draft internal review
- Second draft internal review
- External review
- Final draft and pre-publication
Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.
Evidence exclusion criteria
Our policy
Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.
Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.
Standard exclusions for scoping literature:
- Animal studies
- Original research is not written in English
Possible exclusions for reviewed literature:
- Sample size too small or study underpowered
- Bias evident or promotional literature
- Population not relevant
- Intervention/treatment not relevant
- Outcomes not relevant
- Outcomes have no clear evidence of clinical effectiveness
- Setting not relevant
- Not relevant to UK
- Incorrect study type
- Review article
- Duplicate reference
Organizational, behavioural and financial barriers
Our policy
The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.
- Feasibility
- Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
- Organizational and Financial Impact Analysis
- Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
- Eligible population
- Current interventions
- Likely uptake of new intervention or recommendation
- Cost of the current or new intervention mix
- Impact on other costs
- Condition-related costs
- In-direct costs and service impacts
- Time dependencies
- Cost-effectiveness or cost-benefit analysis studies are identified where available.
We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.
Declarations of interest
Our policy
Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:
- Personal financial interests
- Personal family interest
- Personal non-financial interest
- Non-personal financial gain or benefit
Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.
Who should declare competing interests?
Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.
Competing interests declared for this topic:
None.
References
- BMJ Best Practice (2021) Pressure ulcer. BMJ Publishing Group. http://bestpractice.bmj.com
- Briggs, M., Collinson, M., Wilson, L., et al. (2013) The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients. BMC Nursing 12(1), 19. [Abstract]
- Coleman, S., Nelson, E. A., Keen, J., et al. (2014) Developing a pressure ulcer risk factor minimum data set and risk assessment framework. Journal of Advanced Nursing 70(10), 2339-2352. [Free Full-text]
- EPUAP/NPIAP/PPPIA (2019) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance. https://www.internationalguideline.com
- Gefen, A., Alves, P., Ciprandi, G., et al. (2020) Device-related pressure ulcers: SECURE prevention. Journal of Wound Care 29(Sup2a), S1-S52. [Abstract] [Free Full-text]
- Gorecki, C., Brown, J.M., Nelson, E.A., et al. (2009) Impact of pressure ulcers on quality of life in older patients: a systematic review. Journal of the American Geriatrics Society 57(7), 1175-1183. [Abstract]
- Gorecki, C., Nixon, J., Madill, A., et al. (2012) What influences the impact of pressure ulcers on health-related quality of life? A qualitative patient-focused exploration of contributory factors. Journal of Tissue Viability 21(1), 3-12. [Abstract]
- Graves, N., Birrell, F. and Whitby, M. (2005) Effect of pressure ulcers on length of hospital stay. Infection Control and Hospital Epidemiology 26(3), 293-297. [Free Full-text]
- Greenwood, C., Nelson, E. A., Nixon, J., et al. (2022) Comparative effectiveness of heel-specific medical devices for the prevention of heel pressure ulcers: A systematic review. Journal of Tissue Viability 31(4), 579-592. [Abstract] [Free Full-text]
- McGinnis, E., Greenwood, D. C., Nelson, E. A. and Nixon, J. (2014a) A prospective cohort study of prognostic factors for the healing of heel pressure ulcers. Age and Ageing 43(2), 267-271. [Abstract]
- McGinnis, E., Briggs, M., Collinson, M., et al. (2014b) Pressure ulcer related pain in community populations: a prevalence survey. BMC Nursing 13, 16. [Abstract]
- NHS England (2019) React to Red – Reducing pressure ulcers in care home settings. NHS England. http://www.england.nhs.uk [Free Full-text]
- NICE (2015) Pressure Ulcers Quality standard [QS89]. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
- NICE (2022a) Pressure ulcers: prevention and management. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
- NICE (2022b) Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
- Nixon, J., Brown, S., Smith, I. L., et al. (2019) Comparing alternating pressure mattresses and high-specification foam mattresses to prevent pressure ulcers in high-risk patients: the PRESSURE 2 RCT. Health Technology Assessment (Winchester, England) 23(52), 1-176. [Abstract] [Free Full-text]
- NPIAP (2016) Pressure Injury Stages. National Pressure Injury Advisory Panel. https://npiap.com [Free Full-text]
- OHID (2022) Pressure ulcers: applying All Our Health. Office for Health Improvement and Disparities. http://www.gov.uk [Free Full-text]
- Parafricta (2015) User guide for garments. Frontier Medical Group. https://parafricta.com [Free Full-text]
- Shi, C., Dumville, J. C., Cullum, N., et al. (2021) Beds, overlays and mattresses for preventing and treating pressure ulcers: an overview of Cochrane Reviews and network meta-analysis (Cochrane Review/Cochrane Intervention Protocol). Issue 8. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
- Stevenson, R., Collinson, M., Henderson, V., et al. (2013) The prevalence of pressure ulcers in community settings: an observational study. International Journal of Nursing Studies 50(11), 1550-1557. [Abstract]
- Theisen, S., Drabik, A. and Stock, S. (2012) Pressure ulcers in older hospitalised patients and its impact on length of stay: a retrospective observational study. Journal of Clinical Nursing 21(3-4), 380-387. [Free Full-text]
- Wood, J., Brown, B., Bartley, A., et al. (2019) Reducing pressure ulcers across multiple care settings using a collaborative approach. BMJ Open Quality 8(3), e000409. [Abstract] [Free Full-text]