Under pressure: How to overcome the pressure ulcer problem in rehab

Rehab professionals encounter pressure ulcers more frequently than we would like to admit.  But you must wonder, with something that theoretically should be very preventable… are we truly understanding pressure ulcer staging and prevention, so we are best equipped to move our patients through a path to recovery?  A rehab team has so many layers of unique areas of expertise and there are many ways that the team can come together and tackle the problem of pressure ulcers!

Learn more about the role of Occupational Therapists as valuable members of the wound care team!

Team Approach is Best!

We do not work as silos, right?  We function best in every aspect of care when we work as one cohesive unit, all bringing our individual perspective to the situation.  We all have something valuable to contribute when it comes to pressure ulcer prevention and treatment of pressure ulcers when they do happen, and it’s important that we all recognize and respect each team members involvement! 

Ideally, having a dedicated wound team is best.  These would be your go-to wound gurus that would not only assess and treat pressure ulcers (and other wounds), but they would be able to answer questions that are posed by other team members, the patient, or the family due to having an increased level of training and experience around wounds.  Better treatment and better customer service – who could ask for more?

Pressure Ulcer Staging

If a dedicated wound team is not possible in your place of work, it is of utmost importance to have a clear understanding of how quickly pressure ulcers can develop (in order to prevent them) and then also to understand how pressure ulcer staging works (in order to make more informed decisions regarding your role in their treatment). 

Like many physical afflictions, pressure ulcers do not affect all people in the same way.  It depends on many physiological factors as well as environment.  Some studies have shown that in higher risk individuals, pressure ulcers (of all stages) can develop in as quickly as one to two hours!  In other individuals, the damage that may occur beneath the surface of the skin, as with deep tissue injury, may not be evident until several days later. 

Because it can happen so quickly in some and be unnoticeable in others, we must all be diligent to frequently inspect skin and be able to recognize what we may encounter in our patients that are unable to reposition themselves or are unable to feel the building pressure under their body parts. 

Here is a quick guide to pressure ulcer staging to get you on your way to a more upskilled approach to assessment!

Stage I:Skin is intact.  Skin is reddened and is not able to be blanched (does not momentarily whiten when quick pressure is applied).  In skin with darker pigmentation, the skin may not look red, but will be a different color than the surrounding area.  The affected area is often warmer than the surrounding tissue.  The affected area may have a different texture (may be either softer of firmer) than the surrounding tissue.
Stage II:The skin is no longer intact, leaving an open wound.  Does not extend past layers of skin.  Can also appear as a fluid filled blister.
Stage III:The wound extends past the layers of the skin into the adipose tissue, but not as deep as the muscle, tendon, or bone.
Stage IV:The wound extends past the skin and adipose tissue, now exposing the muscle, tendon, and/or bone.
Deep tissue injury:Open wound is not present, but tissue beneath the surface has been damaged.  Skin may appear purple or dark red or there may be a blood-filled blister.
Unstageable:The stage is not clear due to the presence of slough.  If you cannot see the base of the ulcer, you cannot assign a stage to it as you may not know how deep the wound goes and what tissues are exposed/involved.

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How much of a problem are pressure ulcers… really?

It is estimated that over 2.5 million people develop pressure ulcers each year in the United States.  And as you may imagine… when they are present it can have a significant effect on a patient’s overall health, their ability to participate in daily life, and their ability to participate in therapy.  Depending on the location of the pressure ulcer and the pressure ulcer staging, they may only be able to tolerate being in any given position for a short amount of time, which limits their ability to participate in functional activities that are meant to strengthen them during their therapy sessions.  They may have an increased amount of pain associated with the pressure ulcer and can only manage short bouts of activity at a time.  If the pressure ulcer is on their foot, the physician may not want them to bear weight to allow better healing.  All of these factors can prolong a person’s stay in rehab and effect their overall outcomes at home. 

Being treated for a pressure ulcer can be an extremely isolating experience as well.  If the wound treatment takes extensive amounts of time, or if the pressure ulcer has large amounts of drainage coming from it, or if there is a foul odor… you may not want your friends or family around too often and you certainly don’t want to deal with those things out in public!  This may be a great opportunity for all clinicians involved to educate patients are caregivers about their situation and remove any sort of stigma associated with pressure ulcers or their treatments!

How can we help?

As mentioned before, working together as a team is one of the best ways we can address the problems our patients are facing, and that includes pressure ulcers!  Here are a few great ways we can collaborate and better serve our patients:


Literally… work together. In the rehab world, PTs and OTs do this all the time (and if they don’t, they should!)  This is a great way to address many different impairments at the same time and to learn from each other.  Some things that one discipline is focusing in on can more easily be carried over to future individual sessions after the patient has been observed performing them! 

We can use this same concept in wound care!  PTs or OTs (and even SLPs) can participate in a wound dressing change with the nurse.  The nurse can lead the way if the therapist is not well versed in the wound world, but the therapist can assess and identify other avenues of treatment that may assist in wound healing.  As they see the wound uncovered, they can determine if any type of modality can be used as an adjunct to wound healing. 

This could even be simply related to the pain that is incurred during the wound dressing change itself.  With a bit of scheduling gymnastics, therapy can coordinate with nursing as to when a dressing change will occur and time the application of stim, ultrasound, etc. in order to alleviate pain and assist with the process of the wound treatment.  These modalities can also act to increase circulation to the area and indirectly help with wound healing. 

If SLP is co-treating with nursing, this may be a great opportunity to see how well the patient or their caregiver will be able to carryover the steps involved in a dressing change or even if they can carryover the importance of repositioning and strategies to offload high pressure areas.


As we learned, pressure ulcers can develop quickly in higher risk individuals.  If we can prevent them from happening in the first place… that’s where we want to be.  We can certainly work together to be most effective in prevention.  Nursing will be inspecting skin at regular intervals, but OTs usually see a whole lot of skin in the rehab setting too!  Being mindful of any changes or anything that looks out of the ordinary during bathing and dressing tasks will be a great help in continuously assessing for signs of pressure which may lead to ulcerations down the road. 

Therapists are also constantly assessing levels of pain.  Pain could be an indicator of pressure, so it’s imperative that we really get down to the bottom of the source of pain rather than simply asking if the patient is due for their next pill.  This way, we can adjust equipment or positioning and possibly prevent a pressure ulcer from forming.


This is definitely an area that therapy and nursing overlaps.  This should be quite intuitive in how the different disciplines would work together to come up with the best positioning devices, strategies, schedules, and overall plan to address the individual needs of the patient.  Therapy can recommend and provide the appropriate wheelchair, cushion, or any other specialty items needed.  Nursing can evaluate the bed and mattress and initiate a turning and/or out of bed schedule.  Then as we go through our days, we can be in constant communication with the other about what’s next.  If the cushion turns out to be uncomfortable, the therapist can proactively provide and “option B” for the evening shift nurse to trial with the patient until they can get back in the next day to evaluate the situation.  If therapy is assisting the patient back to bed at the end of a session, the nurse should be notified as to how they are positioned, so they can keep track of when they need to be repositioned and how.  Positioning isn’t new for any of us, but we have to communicate well and always be on the same page.

Refine your skills

Not all teams start out with wound care experts.  But it doesn’t mean it should stay that way!  There are many avenues you can go down to find out more about how to address pressure ulcers and how to assess and treat wounds in general.  You may start of with reading some articles.  Finding out the latest and greatest research is a good place to start.  Taking continuing education classes will give you more hands-on, practical knowledge.  (Scroll to the bottom to find a link to ARC’s, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician.)  You can take it a step further and become Wound Care Certified!  Visit this website to see the benefits of becoming certified and what steps you need to take.

Wound care is not everyone’s cup of tea.  But, pressure ulcers are real… and they can show up real quick if we aren’t careful!  Working as a team and finding ways to build in a comprehensive program for pressure ulcer treatment and pressure ulcer prevention is where you will give your patients, yourself, and your co-workers the best rehab experience possible.

Want to see some videos about pressure ulcer and other wound management techniques? CheckCheck out these videos from our resident guru, Michelle, that you can apply immediately…no matter what setting you work in.

If you are interested in upskilling your practice, check out A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This engaging and super-practical seminar will give you the hands-on skills and the confidence you need to be able to assess and manage all types of wounds.

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