If pressure ulcers were apples: A fun inservice program

 By Karen Culp, RN, WCC

I’m one of the nurses responsible for the pressure ulcer prevention education program at the 150-bed skilled nursing facility where I work. We try to keep education sessions simple, fun, and interactive. One day, our administrator asked us to develop a crossword puzzle and “minute to win it” education game that would be appropriate for all staff—registered nurses, licensed practical nurses, certified nursing assistants, and staff from administration, the business office, scheduling, maintenance, dietary, and housekeeping.

We found a wonderful article by Patricia Turner, “Apples to ulcers: Tips for staging pressure ulcers,” that prompted us to develop “If pressure ulcers were apples,” a three-part program consisting of information about pressure ulcers, the “minute to win it” game, and a crossword puzzle. Here are the three parts of the program so you can replicate it in your organization.

Part 1: About pressure ulcers

We first provide an overview of pressure ulcers and their staging. We build on information from Turner’s article, which explains that the stages of pressure ulcers can be compared to apples in various conditions. As Turner writes, “The old saying is ‘An apple a day keeps the doctor away.’ Well, how about, ‘An apple a day can help take pressure ulcer staging confusion away.’”

You can access all the descriptions in  Turner’s article, but here is an example to give you a “flavor” of the comparisons.

Stage II

These pressure ulcers are defined as partial thickness loss of the dermis indicated by a shallow, open ulcer. The key here is that there isn’t a lot of depth to these wounds and the wound is right at the layer of the dermis, the innermost layer of skin. Think of an apple being peeled. Just the layer of outside “skin” is being removed when we carefully peel an apple. The same superficial layer has been removed or compromised in a Stage II pressure ulcer. These wounds will not have slough, and they will be superficial in nature.

Part 2: “If pressure ulcers were apples” crossword puzzle

Click here for the crossword puzzle I developed and that we give participants to complete.



1. What stage of pressure ulcer would you expect if your apple had a soft dark spot?

3. What type of ulcer is a localized injury to the skin or underlying tissue, usually over a bony prominence?

5. What stage of pressure ulcer would you expect if the apple were peeled carefully so just the outside layer was missing?

6. What a day keeps the doctor away?

8. What stage of pressure ulcer would you expect if you have a normal red apple and you’re unable to change the  red color by touching the apple?


2. What stage of pressure ulcer would you expect if you took a bite out of the apple and you’re into the juicy meat of the apple?

4. What stage of pressure ulcer would you expect if you had an apple completely covered with caramel so you really don’t know the state of the apple underneath?

7. What stage of pressure ulcer would you expect if you were to bite into the  apple and you would get to the core?


Across: 1, DTI; 3, pressure; 5, two; 6, apple; 8, one. Down: 2, three; 4, unstageable; 7, four.

Part 3: “Minute to win it” game

Here is how to run this fun, interactive game, which reinforces the didactic material.


• 6 apples to represent each stage of pressure: Stage I, red apple; Stage II, spot with apple peeled; Stage III, apple with chunk out of it; Stage IV, apple with core visible; Unstageable, caramel apple; DTI (deep tissue injury), apple with bruise.

• 6 place cards (8.5″ wide by 5″ long) to represent each stage of pressure. Laminate the cards and include information discussed in the presentation.

• 6 bowls

• 2 oven mitts

• 1 set of tongs

• 1 minute timer

• 1 tray

• 1 1ong table


• Place apples on the tray in no particular order.

• Place oven mitts and tongs next to the tray with apples.

• Put the place cards in order (Stage I, Stage II, and so on) along the edge of the table.

Game rules

Tell participants:

1. You will have 1 minute to place all six apples of different stages on place cards.

2. Pick up the apples one at a time using tongs and wearing oven mitts.

3. Carry the apples to the place card that correctly matches the stage of the apple.

4. If you drop the apple or put the apple on the wrong place card, you will have to start over with that apple.

Putting it all together

The information section and the crossword puzzle are put in the staff’s break room so they can work on it at their convenience during the day. Completed puzzles are entered into a drawing for prizes. The “minute to win it” game is set up for 2  hours so that staff could participate either when coming on or leaving their shift. The game itself lasts 1 minute for each player.

Learning can be fun

Staff responded enthusiastically to the program, giving us much positive feedback. Some participation came from unexpected sources. During the inservice, one of the kitchen staff said she wouldn’t be able to play because she was not a nurse or certified nursing assistant. I encouraged  her to read the information and try the game. She was able to put all the apples in the correct order and had a fun learning experience. We plan to offer the inservice again, perhaps as an annual event.

Selected references

Burruss N, Popkess A. The diverse learning needs of students. In: Billings DM, Halstead JA, eds. Teaching in Nursing. 4th ed. St. Louis, MO: Saunders; 2011.

NPUAP pressure ulcer stages/categories. www.npuap.org/resources/educational-and-clinicalresources/npuap-pressure-ulcer-stagescategories.

Turner P. Apples to ulcers: Tips for staging pressure ulcers. http://mkt.medline.com/clinical-blog/channels/clinical-solutions/apples-to-ulcers-tips-for-stagingpressure-ulcers/

Karen Culp is a nurse manager at the Manitowoc Health and Rehabilitation Center in Manitowoc, Wisconsin.

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One Thought to “If pressure ulcers were apples: A fun inservice program”

  1. Angy

    Awesome idea…. this would be great for our unit. Thank you

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