Pressure Ulcers: The PICOT Question

Pressure ulcers are often described as indicators of nursing care quality. Also known as a bed sore, it is local damage to the skin or the tissues under it due to pressure and friction. Most often occurring in immobile patients confined to beds or wheelchairs, pressure ulcers are particularly common in intensive care units.


Pressure ulcers are one of the most common skin conditions, particularly in long-term care. According to Hahnel et al. (3), the prevalence of pressure ulcers in US hospitals reaches as high as 30% among seniors. Furthermore, patients in long-term care suffer more bed sores than those merely hospitalized.

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Clinical Presentation

Different stages of a stage ulcer have progressively worse appearances. According to Compton and Thomas (50), stage I is characterized by a non-blanchable redness, and stage II is a shallow open ulcer or a blister. Stage III and IV exhibit full thickness tissue loss, with stage III not exposing bone, tendon or muscle, unlike stage IV, which can even extend into muscle.

The depth of an ulcer primarily depends on the anatomical location. Areas such as the nose or ear can exhibit relatively shallow stage III ulcers due to the lack of subcutaneous tissue, while areas of significant adiposity can develop extremely deep wounds. The determination of the ulcer’s stage may also be complicated by the presence of slough and eschar obscuring the depth of the injury.


A late-stage pressure ulcer is a severe injury in its own right, but there are also numerous complications that can arise from it. As pressure ulcers rarely affect muscle and bone, the primary source of concern lies in the wound’s infection and colonization. Compton and Thomas (144) list common issues as failure to heal, periwound candida infections, cellulitis, osteomyelitis and necrotizing fasciitis.

Periwound candida infections consist of contact dermatitis, fungal infections, and cellulitis. Necrotizing fasciitis is rare but potentially fatal, characterized by spreading necrosis of the skin, tissue, fascia, and at times skeletal muscles. Osteomyelitis is also uncommon, causing the inflammatory destruction of cortical or medullary bone.


It is possible to identify and treat a pressure ulcer before it becomes a danger to the patient. Compton and Thomas (42) recommend the usage of the Braden Scale, which estimates sensory perception, mobility, activity, moisture, nutrition, and friction and shear. Lower values on the sum of these estimates indicate a higher risk of a pressure ulcer.

It is important not to confuse a skin tear with a pressure ulcer, as the two are significantly different injuries. According to LeBlanc et al. (21), “Because skin tears and pressure ulcers share certain risk factors and clinical characteristics, identifying and classifying these wounds as distinct, separate wound types can pose a clinical challenge to health care professionals.” However, the wounds are treated differently, which means an incorrect diagnosis puts the patient at risk.

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Pressure ulcers are both dangerous and prevalent in patients under hospital care. However, with proper methods, they can be detected and prevented before they develop to a critical degree. As such, a PICOT question can be postulated: in patients identified as at high risk for pressure ulcer development (P), does the initiation of a pressure ulcer protocol in the emergency department (I) as compared to usual care (C) reduce the incidence of hospital-acquired pressure ulcers (O) on day 3 of hospitalization (T)?

Works Cited

Compton, Gregory A., and David R. Thomas. Pressure Ulcers in the Aging Population: A Guide for Clinicians. Humana Press, 2014.

Hahnel, Elisabeth, et al. “The epidemiology of skin conditions in the aged: A systematic review.” Journal of Tissue Viability, vol. 4, 2016, pp. 1-9.

LeBlanc, Kimberly, et al. “Clinical Challenges of Differentiating Skin Tears From Pressure Ulcers.” EWMA Journal, vol. 16, no. 1, 2016, pp. 17-23.

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