Clinical Notebook

A quick mnemonic for predicting

pressure sores in ED patients
Author: LCDR Richard Maffeo, USN, MSN, San Diego, Calif

he statistics are staggering. For example, the

May 1992 report of the Agency of Health Care
Policy and Research (AHCPR) stated that the incidence of nosocomial pressure ulcers among hospitalized patients ranges from approximately 3% to 30%.1
The estimated cost of treating each patient with
pressure ulcers can be as high as tens of thousands of
dollars.2-4 Emotional and psychological costs to the
patient are more difficult to quantify. It is little wonder
that the AHCPR identified the prevention and care of
pressure ulcers as one of its imperatives.5 Fortunately,
proactive ED nurses are in a unique position to intervene for patients at risk for pressure ulcers before they
enter the patient-care system.
A pressure ulcer is typically defined as a skin lesion that forms when soft tissue overlying a bony
prominence is compressed for a prolonged period of
time.1 Pathogenesis of a pressure ulcer usually follows
a predictable pattern. If a pressure ulcer is left untreated, tissue ischemia resulting from pressure that exceeds capillary closing pressure (12 to 33 mm Hg) inevitably leads to tissue necrosis. Of particular interest
to nurses intervening for patients at risk for pressure
ulcers are reports that suggest that duration of pressure is more crucial to the development of pressure ulcers than is the intensity of the pressure. For example,
in one study, continuous pressure exceeding 60 mm
Hg during a 1- to 2-hour period produced irreversible
tissue damage. However, intermittent pressure up to
180 mm Hg resulted in consistently less damage to tissue. Some patients who experienced intermittent
pressure actually had no cellular injury.6

The views expressed in this article are those of the author and do
not reflect the official position of the Department of the Navy, the
Department of Defense, or the US Government.
Richard Maffeo is Nursing Informatics Officer, Naval Medical Center, San Diego, Calif.
For reprints, write: LCDR Richard Maffeo, USN, MSN, 3279 Old
Bridgeport Way, San Diego, CA 92111.
J Emerg Nurs 1998;24:418-9.
Copyright 1998 by the Emergency Nurses Association.
0099-1767/98 $5.00 + 0 18/9/92242

418 Volume 24, Number 5

Several tools have been developed to help health

care providers identify the patients at greatest risk of
having pressure ulcers develop. The Braden and Norton scales are the most commonly used of these tools.
However, because these scales were developed for
use in the inpatient setting, staff in a busy emergency
department might find them too cumbersome and
elaborate to be suitable for use in the emergency
department.

The incidence of nosocomial

pressure ulcers among
hospitalized patients ranges
from approximately 3% to 30%.
To help the ED nursing staff identify patients at
risk for pressure ulcers, I developed a mnemonic
based on the Braden and Norton scales. Pressure
Sores Are Not Much Fun is a workable tool that can
help busy ED nurses quickly assess a patients risk
status before he or she enters the inpatient setting.
Unless contraindicated in the emergency department
for medical reasons, patients who meet 3 or more of
the mnemonics should be placed on a pressure-reduction mattress or a foam (egg crate) overlay. The literature is replete with evidence that the proper use of
pressure-reduction mattresses decreases the incidence of nosocomial pressure ulcers.7 If use of such a
mattress in the emergency department is not feasible, the nurse should ensure that an overlay order is
on the patients chart and inform the receiving unit
that an overlay should be placed on the patients bed
before the patient arrives.
Now, the mnemonic:
Pressure: (P)osition change. Patients who cannot
change their position in bed or a chair without assistance because of such conditions as decreased level
of consciousness, coma, or paralysis meet part of the

Maffeo/JOURNAL OF EMERGENCY NURSING

A Quick Mnemonic:
Pressure Sores Are Not Much Fun
Position: Is the patient able to change position?
Sensation: Does the patient have impaired sensation?
Activity: Is the patient bedridden? Chairbound?
Nutrition: Does the patient have a history of poor
dietary intake?
Moisture: Is it likely that the patient is incontinent?
Friction shear: Are difficult bed/chair transfers likely
because of spasticity or contractures?

mnemonic criteria. Patients strapped to backboards

should not be overlooked. Many patients strapped to
backboards typically remain on the rigid and unyielding surface of the backboard for as long as 3 hours
plenty of time to develop multiple pressure ulcers.
Sores: (S)ensation. Patients with impaired sensory and pain perceptionas can occur with coma, diabetic neuropathy, or paralysisare at risk for having
pressure ulcers develop5,8 and meet part of the
mnemonic criteria.
Are: (A)ctivityspecifically the lack of activity
is another important risk factor. One study reported
that nearly 8% of bedridden and chairbound patients
entering a hospital without a pressure ulcer developed one within 3 weeks.9 The ED nurse can anticipate which patients are likely to be confined to
bed or a chair and, using the mnemonic, initiate early
intervention.
Not: (N)utrition. Numerous studies provide evidence that inadequate dietary intake of calories, protein, and iron predisposes patients to the development of pressure ulcers.1 Patients with a history of
poor nutritional intake or those who are likely to experience poor dietary intake as a result of their injury/illness meet the mnemonic criteria.
Much: (M)oisture, such as that from urine, wound
drainage, or feces, can irritate skin and make it more
susceptible to breakdown. Patients admitted to the
emergency department with a history of incontinence
or those who are likely to be incontinent because of
current illness or injury also meet part of the mnemonic criteria.
Fun: (F)riction shear. Shear-type injuries occur
when skin remains stationary and the underlying tissue shifts, which occurs when a person slides down
in bed or is transferred improperly from the bed to a
chair. Patients with contractures, spasticity, or who
are otherwise unable to transfer to and from a bed or
change position without assistance are at risk.

Whereas no scale or mnemonic can replace good

nursing care, use of such tools can be an important
adjunct to quality patient care. Pressure Sores Are
Not Much Fun is one more instrument in the busy
nurses repertoire of skills designed to move the patient toward optimum health. ED nurses who identify
patients meeting 3 or more of the mnemonic criteria
can intervene on their behalf to improve the quality of
their care; otherwise, serious skin lesions might develop, and as anyone who has taken care of patients
with pressure ulcers knows, pressure sores are not
much fun.

Shear-type injuries occur

when skin remains stationary
and the underlying tissue
shifts, which occurs when a
person slides down in bed.
References
1. Bergstrom N, Allman RM, Carlson CE, Eaglstein W,
Frantz RA, Garber SL, et al. Pressure ulcers in adults: prediction and prevention. Rockville (MD): Dept. of Health and
Human Services (US), Public Health Service, Agency for
Health Care Policy and Research; 1992. Clinical practice
guideline No. 3.
2. Fleischer MI, Bryant D. Evaluating replacement mattresses. Nurs Manage 1997;28:38-41.
3. Ferrell BA, Osterweil D, Christenson P. A randomized trial
of low-air-loss beds for treatment of pressure ulcers. JAMA
1993;269:494-7.
4. OSullivan KL, Engrave LH, Maier RV, Pilcher SL, Isik FF,
Copass MK. Pressure sores in the acute trauma patient: incidence and causes. J Trauma 1997;42:276-8.
5. Leigh IH, Bennett G. Pressure ulcers: prevalence, etiology,
and treatment modalitiesa review. Am J Surg 1994;
167:25S-30S.
6. Jesurum J, Joseph K, Davis JM, Suki R. Balloons, beds, and
breakdown. Crit Care Nurs Clin North Am 1996;8:423-40.
7. Carlson JM, Payette MJ, Vervena LP. Seating orthosis design for prevention of decubitus ulcers. J Prosthet Orthot
1995;7:51-61.
8. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost-effectiveness of an air suspension bed in the
prevention of pressure ulcers. JAMA 1993;269:1139-43.
9. Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci
AA. Pressure ulcer risk factors among hospitalized patients
with activity limitation. JAMA 1995;273:865-70.

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