You’re in the middle of a mobility assessment when you notice a stage II wound on your patient’s sacrum that is preventing them from sitting up for therapy. This is a common scenario in acute care and skilled nursing, and a solid grasp of pressure ulcer management is essential for your Plan of Care (POC) and patient education.
What is a Pressure Ulcer?
A pressure ulcer (also called a decubitus ulcer, bed sore, or pressure injury) is localized damage to the skin and underlying tissue caused by prolonged, unrelieved pressure, often over a bony prominence. The pressure occludes capillaries (typically at pressures above 32 mmHg), leading to ischemia, cell death, and tissue necrosis. They are categorized into stages (1-4) based on tissue depth, with additional classifications for unstageable and deep tissue injuries.
Why Pressure Ulcers Matter in Physical Therapy Practice
Pressure ulcers are a critical comorbidity that directly impacts your patient’s functional mobility and safety. Pain from the wound can limit participation in transfers, gait training, and bed mobility. Furthermore, a pressure ulcer is a major risk factor for infection and can significantly prolong hospital stays. Your POC must integrate wound precautions, positioning strategies, and pressure offloading to promote healing while maintaining functional gains.
What You’ll See in the Clinic
You will see patients with limited mobility, sensory deficits, or malnutrition who are at high risk. Presentation varies from a localized area of non-blanchable erythema (Stage 1) to a deep crater exposing bone or muscle (Stage 4). Patients may report localized pain or the wound may be insensate. You must always document wound status and ensure the patient is positioned off the site.
“Patient is a 72-year-old male s/p CVA with a Stage 3 pressure ulcer on the right heel. He is non-weight-bearing on the right LE. I will focus on left UE/LE strengthening, seated balance, and wheelchair mobility training. I will educate on strict offloading of the right heel with a foam boot and repositioning every 2 hours.”
Common Pitfall & Pro Tip
⚠️ Pitfall: Placing the patient directly on a donut cushion for a sacral ulcer. These devices actually increase pressure around the wound and decrease blood flow to the area, which can worsen tissue ischemia.
💡 Pro Tip: Use a 30-degree lateral incline for patients with sacral ulcers. This position offloads the sacrum and ischial tuberosities while keeping the patient stable for functional activities. Always incorporate a pressure relief protocol (e.g., push-ups every 30 minutes in a wheelchair) into your treatment session.
Memory Aid for Pressure Ulcers
Think “P.R.E.S.S.U.R.E.” to remember the key risk factors:
- Pressure, Reduced mobility, Elderly, Sensory loss, Shear/Friction, Undernutrition, Reduced perfusion, Edema.
This mnemonic helps you quickly screen patients on initial exam to determine their risk level and prioritize preventative education.
NPTE Connection
Expect questions on wound staging, identifying risk factors, and selecting appropriate positioning/repositioning schedules. You will also need to know the Braden Scale for risk assessment and understand the contraindications for physical therapy (e.g., avoiding pressure over the wound site).
Related Physical Therapy Concepts
Understanding pressure ulcers connects directly to Wound Care Management and Positioning and Draping for therapeutic exercise. It is also a primary consideration in Spinal Cord Injury Rehabilitation, where sensory loss and immobility create high risk, and in Geriatric Physical Therapy, where skin integrity is a key component of fall and frailty assessments.
Quick Reference
✓ Priority level: Critical – High risk for infection and delayed discharge ✓ PT Interventions/Considerations: • Strict offloading of the wound site (reposition every 2 hours) • Patient/caregiver education on skin inspection and pressure relief • Therapeutic exercise to improve mobility and transfer independence • Coordinate with nursing for proper wound care and dressing changes • Assess for and address nutritional deficits (refer to dietitian)
Bottom line: A pressure ulcer is a serious comorbidity that demands your respect. By prioritizing offloading and integrating functional mobility training, you can help your patient heal and regain independence safely.