Care Indicators - Pressure Ulcer

Pressure Ulcer


Pressure ulcers/pressure sores are a frequently occurring health problem. They form a complication that often needs to be prevented among at-risk clients. Pressure ulcers are painful and reduce quality of life. Moreover, treatment involves high costs.
In the international guidelines of NPUAP/EPUAP/PPPIA (2014), a pressure ulcer is defined as ‘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.’
Pressure ulcers are subdivided into categories, described by the international guidelines of the NPUAP/EPUAP/PPPIA (2014) as follows:

Category I: Non-blanchable erythema.

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Category II: Partial thickness.

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous blister.

Category III: Full thickness skin loss.

Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Category IV: Full thickness tissue loss.

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.

Unstageable: depth unknown.

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.

Suspected deep tissue injury: depth unknown

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.


Pressure ulcers are a widespread phenomenon. Prevalence figures quoted internationally range from 0 to 46% in hospitals and 4.1 to 32.2 % in geriatric care. These figures are hard to compare, however, because various measurement methods are used.
Since 1998 the prevalence of pressure ulcers in the Netherlands has been measured annually in a standardised manner with the LPZ. Up until 2004 relatively stable, comparable and high figures were recorded, but since 2004 the incidence of pressure ulcers seems to be falling (see Figure 1). It is difficult to say precisely what the cause of this fall is. The fact that considerable attention has been given to the issue of pressure ulcers is sure to have exerted a positive influence.

The major drop in the prevalence of pressure ulcers in recent years also brings the danger of the issue receiving less attention. Figure 1 indicates a slight increase again in the prevalence in 2014. Although it would be premature to draw conclusions based on one measurement, workers in the field are also reporting that they are seeing more pressure ulcers again. So, continuing attention for pressure ulcers is an imperative for every care provider and care institution.
Information about the prevalence in Austria and Switzerland can be found in Halfens et al (2013).

Prevalence of Pressure Ulcers Category II and higher 1998- 2014
Figure 1: Prevalence of Pressure Ulcers, Category II and higher 1998- 2014 (Halfens et al, 2014)

LPZ measurement

In order to increase the reliability of the measurement, various categories of pressure ulcers are measured in the LPZ instrument by two care providers. Furthermore, data are collected about where and when pressure ulcers arise (before or after admission), and which (preventative) interventions are carried out. The Care Dependency Scale is used to measure whether clients are at risk of pressure ulcers. In addition, a number of quality indicators such as the presence of guidelines are measured at institutional and departmental level.


  • National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.
  • Halfens, RJG, Meesterberends E, Meijers JMM, Neyens JCL, Rondas AALM, Rijcken S, Wolters SMP and Schols JMGA (2014). Landelijke Prevalentiemeting Zorgproblemen: rapportage resultaten 2014. Maastricht: Maastricht University, CAPHRI. LPZ Rapport 2014. Maastricht: Universiteit Maastricht, CAPHRI.
  • Halfens, RJG, Meesterberends E, van Nie-Visser NC, Lohrmann C, Schönherr S, Meijers JMM, Hahn S, Vangelooven C and Schols JMGA (2013). International prevalence measurement of care problems: results. Journal of Advanced Nursing; 69(9): e5-e17.

Use the LPZ within your institution?