**6. Pressure ulcer prevention**

**Table 3.** Pressure ulcer injury/ulcer stages/categories.

330 Wound Healing - New insights into Ancient Challenges

catheters and fecal containment devices [13].

contains blood vessels, elastin and collagen fibers [13].

Mucosal pressure injuries are *pressure injuries found on mucous membranes with a history of a medical device in use at the location of the ulcer* [1]. A mucous membrane is the moist lining of a body cavity, such as the gastrointestinal tract, nasal passages, urinary tract and vaginal canal, that communicates with the exterior. When pressure is applied to a mucous membrane, ischemia can result that can lead to a pressure ulcer. Mucous membranes are vulnerable to pressure especially related to medical devices such as oxygen tubing, feeding tubes, urinary

The anatomy of mucous membranes impacts the staging or categorizing of a mucous mem‐ brane pressure injury [13]. There are two types of mucous membrane tissue; nonkeratinized stratified squamous epithelium and an underlying connective tissue layer, the lamina propria. These layers are similar to the epidermis and dermis and are connected via rete pegs. At the interface of the two layers is a basal laminal layer. The epithelial layer is continuously renewed through migration of lower layers of epithelium to the surface. The epithelium of the mucosa, although is not keratinized like the epithelium of the skin. The lamina propria generally

There are several factors that have been associated with the development of pressure ulcers. Many of these factors affect an individual's ability to withstand episodes of pressure and shear as well as decrease the length of time or amount of pressure necessary to cause tissue damage. Risk factors that can lead to pressure ulcer development include age, immobility, nutritional deficiencies, skin moisture and incontinence, vasopressor use, chronic diseases such as diabetes or stroke, smoking, behavioral issues leading to noncompliance, poor general health and sensory loss [14, 15]. No single factor can explain all pressure ulcers rather it is a complex interaction among factors which increases the probability of pressure ulcer development


**Table 4.** Pressure ulcer risk assessment tools.

Prevention begins with identifying those individuals at risk for pressure ulcer development. A pressure ulcer risk assessment instrument that has been validated for use in the specific age group should be utilized. In the Unites States, the most common adult risk assessment instruments are The Braden and Norton scales that have been tested for validity in predicting pressure ulcer development risk [7, 16]. In Britain, the most common scales are the Braden and the Waterlow. The Jackson Cubbin Scale is specific to European critical care (**Table 4**).

These scales will identify specific factors related to assessment categories that place an individual at risk for pressure ulcer development. Once specific factors are identified, a prevention plan to address those factors can be implemented to reduce or eliminate the risk of pressure ulcer development [3, 16]. With the implementation of an evidence‐based pressure ulcer prevention plan, pressure reduction can occur which will preserve the microcirculation and prevent the development of pressure ulcers [17]. A pressure ulcer prevention plan is multifaceted. Factors related to prevention and discussed further in treatment, as these factors are also included in a treatment plan, include; mobility, moisture and continence care, nutrition and hydration, support surfaces, documentation and education. No single intervention has been found that will consistently, reliably and completely reduce pressure ulcer development. Pressure ulcer prevention involves multiple interventions and a multidisciplinary team to affect the identified factors and reduce the risk of pressure ulcer development.
