1.2 Describe the changes that occur when damage caused by pressure develops

This guide will help you answer 1.2 Describe the changes that occur when damage caused by pressure develops.

Damage caused by pressure, commonly called a pressure ulcer, pressure sore or bed sore, happens when an area of skin and the tissue underneath are harmed by prolonged pressure. The most at risk are people with reduced mobility, illness or frailty. This harm often takes place when someone sits or lies in the same position for too long. Continuous pressure squeezes blood vessels and stops oxygen and nutrients reaching the skin and tissue. Without these, cells start to die and breakdown happens.

The skin is the largest organ in the body. It works as a protective barrier. When the skin is damaged by pressure, the breakdown process moves through several stages.

The First Signs of Pressure Damage

Early changes are subtle but important to notice. They usually appear before the skin splits or breaks. This stage is sometimes called “non-blanching erythema”.

Key points in early changes:

• The skin area looks red or darker than usual. In people with darker skin tones, it may look blue, purple, or feel warm.
• The redness or discolouration does not turn white (“blanch”) when pressed gently with a finger.
• The area may feel warmer or cooler to the touch than the skin nearby.
• The person may notice discomfort, itchiness, tingling, or tenderness in that spot.

At this stage, the skin remains whole (unbroken). Quick action can stop further harm.

Progression to Open Wounds

If the pressure and lack of blood flow continues, the damage gets worse. The skin may start to break. This leads to an open wound. The depth and seriousness of the wound increases as time passes.

Changes that appear as the damage progresses:

• The skin may blister or develop a shallow break.
• The area might weep clear fluid or pus.
• The wound edges may look irregular.
• Pain usually gets worse.

When the top layer (epidermis) breaks, bacteria can enter. This raises the risk of infection.

Development of Pressure Ulcer Stages

Health professionals often use a system of four stages to describe pressure ulcers. These stages show increasing depth and severity. Here’s how each stage develops:

Stage 1: Red or Discoloured Intact Skin

• Red, warm, or discoloured patch on the skin that does not blanch.
• No open wound.
• Possible pain, swelling or firmness.
• The skin is still intact.

Stage 2: Partial Loss of Skin Thickness

• The top layer of skin (epidermis) is broken or lost.
• The wound is shallow, like an abrasion or blister.
• Clear fluid may weep.
• The area is more painful.
• There may be some swelling around the wound.

Stage 3: Full Thickness Skin Loss

• Both the epidermis and deeper dermis are lost.
• The ulcer extends into subcutaneous tissue (the layer under the skin).
• The wound appears as a deep crater.
• Tissue may look yellow (slough), which is dead tissue.
• Edges may be rolled.
• There can be visible fat, but not muscle or bone.

Stage 4: Full Thickness Tissue Loss with Exposure

• Extends through all the skin layers and into muscle, bone, or supporting structures.
• Wound may have black, dead tissue (called eschar).
• Tunnels (sinuses) or tracks from the wound may have formed.
• Bone or tendon can sometimes be seen or felt.
• High risk of serious infection.

Unstageable and Deep Tissue Pressure Injuries

Sometimes, the stage is “unstageable”. This means the base is covered by dead, yellow (slough) or black (eschar) tissue. The real depth cannot be seen until this is cleaned away.

A “deep tissue pressure injury” may look like a dark bruise but may not be open. These can worsen quickly, forming deep sores under the skin with little surface change at first.

Physical Changes in the Skin and Underlying Tissue

As the pressure damage develops, several changes happen to the skin and the tissue below:

• Oxygen and nutrient loss: Consistent pressure blocks blood flow, so cells do not receive what they need to stay alive.
• Cell death: Without blood, skin and tissue cells die off, causing softening, discolouration, and breakdown.
• Tissue breakdown: The dead tissue separates from living tissue, creating an open wound.
• Infection risk: When the skin barrier is broken, bacteria can enter and cause local or spreading infections.
• Fluid and electrolyte loss: Open wounds may ooze fluid, causing dehydration and changes to the body’s chemical balance.
• Inflammation: The body reacts with swelling, heat, redness, and pain as it tries to repair the injury.

Common Pressure Points and Their Risks

Pressure ulcers most often appear where bones are near the surface and pressure is stronger. Key areas include:

• Heels
• Ankles
• Hips
• Sacrum (lower back)
• Elbows
• Shoulders
• Back of the head

In people who use wheelchairs, the buttocks and backs of the thighs are at risk. For people who lie in bed for long periods, the heels, coccyx, hips, shoulders, and back of the head are common sites.

Associated Changes and Complications

If the damage is not spotted or treated early, changes can become severe. Some further issues include:

• Infection: Skin infections (cellulitis), deeper infections in muscle or bone, or widespread infection (sepsis) can occur.
• Pain and discomfort: Nerve endings are exposed or destroyed, affecting comfort and quality of life.
• Prolonged healing: Pressure ulcers can take a long time to heal, especially deeper wounds or if other health problems exist.
• Scarring and reduced mobility: Intense wounds may leave scars or tighten skin and other tissue, affecting movement.

Risk Factors Making Damage More Likely

Some conditions and situations make pressure damage more likely or more severe:

• Poor mobility due to illness, injury or weakness
• Poor nutrition or dehydration
• Loss of feeling (sensory impairment), so pain or discomfort is not noticed
• Older age – skin becomes thinner and less elastic
• Damaged or wet skin from sweat, urine or faeces
• Medical conditions affecting blood flow (e.g. diabetes, heart problems)
• Low body weight or very little fat under the skin

These factors reduce the skin’s ability to resist pressure and delay healing.

The Role of Shear and Friction in Damage

Shear and friction can make the harm worse:

• Shear happens when layers of skin move in different directions. For example, if someone slips down in bed, their skin stays against the sheets but their bones move downwards. This stretches and tears skin and tissue.
• Friction happens when skin rubs against bedding, clothing or other surfaces, causing heat and damage. Repeated friction can wear down skin.

These forces, alongside pressure, speed up the breakdown process. The area can open or become deeper more quickly.

Recognising Signs Early

Spotting early pressure damage makes a big difference to outcomes. Signs to watch for:

• Unusual redness or discolouration that does not go away
• Skin is warmer, cooler, or softer than surrounding areas
• Area is swollen or painful
• Itching or tingling in a localised area
• Blisters, open sores, or shiny patches

If these signs are found, pressure should be removed from the area straight away. Reporting to a senior member of staff or nurse is key. Quick action can stop minor damage from becoming a serious wound.

Simple Terms for Key Concepts

• Eschar: Dry, black, dead tissue that covers a wound.
• Slough: Soft, yellow or white tissue that is dead and needs removing for healing.
• Erythema: Redness caused by increased blood flow to the skin.

Supporting Healing and Reducing Risk

Once pressure damage has started, supporting the body to heal and stopping further harm is necessary. Methods include:

• Repositioning the person regularly to relieve pressure
• Using pressure-relieving equipment (special mattresses, cushions and pads)
• Keeping skin clean and dry
• Treating infections quickly
• Ensuring good nutrition and hydration
• Managing any medical problems that affect healing
• Carefully dressing and caring for wounds, following guidance

Staff should follow care plans and organisational policy. Every worker must observe, record and report any changes in skin condition.

Impact on Daily Life

Pressure ulcers can have a big impact on a person’s comfort, health, and wellbeing. They may limit movements, cause ongoing pain, and result in longer hospital stays. Severe ulcers may lead to surgery or long-term complications.

The emotional effect can be just as serious. People may feel upset or embarrassed about their wounds or scars.

Final Thoughts

As a care worker, observing and describing changes accurately helps others act fast. Share what you see, how the area looks and feels, and any complaints from the person receiving care. Follow your setting’s policies and recording systems.

Paying attention to any change in skin condition keeps people safe, comfortable and healthy in your care. Look at those areas most at risk whenever you support with washing or dressing.

Learning to notice early signs, and responding straight away, prevents more serious injury. This is a core part of safe, effective health and social care practice.