Patient/Care Management · 5 min read
Pressure Injury Prevention and Wound Care
Definition and Pathophysiology
A pressure injury (formerly called pressure ulcer) is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device. The primary mechanism is sustained pressure that exceeds capillary closing pressure, causing tissue ischemia; prolonged loss of blood flow leads to cell death and tissue necrosis. Tolerance of soft tissue to pressure and shear is affected by microclimate, nutrition, perfusion, comorbidities, and the condition of the soft tissue.
Table1.8—Mechanismsoftissuedamage
| Factor | Mechanism |
|---|---|
| Pressure | Directmechanicaldeformationoftissueandocclusionofcapillaries |
| Shear | Skinstaysstationarywhileunderlyingtissueshifts(eg slidingdowninbedwiththeheadelevated) . ., , |
| stretchinganddamagingbloodvesselsatdeeperlevels | |
| Friction | Repeatedrubbingagainstsurfacesdamagestheepidermis |
| Moisture | Incontinenceorperspirationmaceratestheskinandreducesitsresilience |
Table1.9—Factorsaffectingtissuetolerance
| Type | Factors |
|---|---|
| Intrinsic | Age nutritionalstatus perfusion sensoryperception mobility , , , , |
| Extrinsic | Pressureintensityandduration shear friction microclimate(heatandmoistureattheskinsurface) , , , |
NPIAP Staging
The National Pressure Injury Advisory Panel (NPIAP) system classifies pressure injuries by the depth of observable tissue damage. Stages are never reverse-staged: a healing Stage 4 is documented as a "healing Stage 4," not a Stage 2.
Table1.10—Npiappressureinjurystages
| Stage | Findings | Keydistinctions | |
|---|---|---|---|
| Stage1 | Intact skin with localized non-blanchable erythema; may be painful , | Indarklypigmentedskinblanchingmay | |
| firm soft warmer orcoolerthanadjacenttissue , , , | notbevisible;lookforcolordifferences | ||
| from surrounding skin Signals at-risk . | |||
| statusrequiringimmediateintervention . | |||
| Purpleormaroondiscolorationisnot | |||
| Stage1(suggestsDTPI) | |||
| Stage2 | Partial -thickness skin loss with exposed dermis; wound bed pink or | Adiposeanddeepertissuesnotvisible; | |
| red and moist; may be an intact or ruptured serum-filled blister | nogranulationtissue slough oreschar , , . | ||
| Notusedforskintears tapeburns , | |||
| (medical adhesive–related skin injury) , | |||
| incontinence-associated or intertriginous | |||
| dermatitis maceration orexcoriation , , | |||
| Stage3 | Full -thickness skin loss; adipose tissue visible; granulation tissue | Sloughorescharmaybepresentbut | |
| androllededges(epibole)oftenpresent | doesnotobscurewounddepth; | ||
| underminingandtunnelingmayoccur . | |||
| Fascia muscle tendon ligament , , , , | |||
| cartilage andbonenotexposed Depth , . | |||
| variesbylocation(shallowoverthe | |||
| nose ear occiput andmalleolus) , , , | |||
| Stage4 | Full -thickness skin and tissue loss with exposed or directly palpable | Sloughorescharmaybepresent;rolled | |
| fascia muscle tendon ligament cartilage orbone , , , , , | edges undermining andtunneling , , 1 frequent;depthvariesbylocation;riskof osteomyelitis |
Table1.10—Npiappressureinjurystages(Continued)
| Stage | Findings | Keydistinctions |
|---|---|---|
| Unstageable | Obscured full -thickness skin and tissue loss; extent cannot be | Oncesloughorescharisremoved a , |
| confirmedbecausesloughorescharcoversthewoundbed | Stage3orStage4injuryisrevealed . | |
| Stableeschar(dry adherent intact , , , | ||
| withouterythemaorfluctuance)onthe | ||
| heeloranischemiclimbshouldnotbe | ||
| softenedorremoved | ||
| Deeptissue | Intact or non-intact skin with localized persistent non-blanchable | Resultsfromintenseorprolonged |
| pressureinjury | deepred maroon orpurplediscoloration orepidermalseparation , , , | pressure and shear at the bone–muscle |
| (DTPI) | revealing a dark wound bed or blood -filled blister | interface Mayevolverapidlytoreveal . |
| theactualextentoftissuelossorresolve | ||
| withouttissueloss | ||
| Medical device– | Injuryconformingtotheshapeofadevice | Skininjuriesarestagedwiththesame |
| related/mucosal | system;mucosalmembranepressure | |
| injuries(eg fromanendotrachealtube) . ., | ||
| cannotbestaged |
Risk Assessment
Table1.11—Pressureinjuryriskassessmenttools
| Tool | Components | Scoring |
|---|---|---|
| BradenScale | Sixsubscales:sensoryperception moisture activity , , , | Range6–23;lowerscore=higherrisk;≤18 |
| mobility nutrition friction/shear Mostwidelyusedtoolin , , . | generallyindicatesrisk | |
| acutecare | ||
| NortonScale | Physicalcondition mentalcondition activity mobility , , , , | Range5–20;≤14indicatesrisk |
| incontinence | ||
| WaterlowScale | Morecomprehensive:bodybuild skintype sex age , , , , | Higherscore=greaterrisk |
| continence mobility appetite tissuemalnutrition , , , , | ||
| neurologicaldeficit surgery medication , , |
Table1.12—Reassessmentfrequency
| Setting | Frequency |
|---|---|
| Allsettings | Onadmission atregularintervals andwheneverthepatient'sconditionchangessignificantly , , |
| Acutecare | Typicallyevery24–48hours(manyfacilitieseveryshiftordaily) |
| Long-term care | Weeklyafteradmission thenatregularintervalsperpolicy , |
| Homecare | Ateachvisit |
High-Risk Anatomical Sites
Table1.13—High-Risksitesbyposition
| Position/cause | Sites |
|---|---|
| Supine | Sacrumandcoccyx(mostcommonsiteoverall) heels(secondmostcommon;especiallyvulnerable , |
| withlimitedmobility) occiput(limitedheadmovement) spineofthescapula elbows , , , | |
| Seated/wheelchair | Ischialtuberosities(highestriskinseatedpatientsandwithprolongedwheelchairuse) |
| Side-lying | Greatertrochanters lateralmalleoli ears lateralknees , , , |
| Medicaldevices | Anywhereadevicecontactsskin:nares(nasogastrictubes) ears(oxygentubing) faceandnasal , , |
| bridge(BiPAPmasks) undercervicalcollars splints andtubing , , , |
Prevention Strategies
Table1.14—Evidence-Basedprevention
| Strategy | Details |
|---|---|
| Repositioning | Turnpatientsinbedatleastevery2hours(individualizedtoriskandsupportsurface);seatedpatientsshift |
| weight every 15 minutes The 30 -degree lateral position reduces pressure over the sacrum and trochanters . | |
| compared with 90 -degree side-lying Keep head of bed ≤30° when possible to reduce shear; use lift sheets . | |
| rather than dragging; float heels off the bed with pillows under the calves or heel -offloading boots | |
| Supportsurfaces | Reactivesurfaceschangeloaddistributiononlyinresponsetoappliedload Activesurfacesmechanically . |
| alterloaddistributionwithorwithoutpatientmovement(eg alternatingpressure) Selectiondependsonrisk . ., . | |
| levelandexistinginjurystage | |
| Skincare | Keepskincleananddry;cleansepromptlyafterincontinenceandapplybarrierproducts;moisturizedryskin; |
| avoidmassageoverbonyprominences(causesadditionaltissuedamage);inspectskinunderdevicesat | |
| leasttwicedailyandpadorrepositiondevices | |
| Nutritionand | Adequateproteinfortissuemaintenanceandrepair;vitaminCandzincsupplementationmaybenefitpatients |
| hydration | with deficiencies; hydration maintains skin elasticity and perfusion; refer at-risk patients to the dietitian (see |
| 110) . |
Assessment of Existing Pressure Injuries
Table1.15—Woundassessmentanddocumentation
| Parameter | Whattodocument | |
|---|---|---|
| Location | Anatomicallandmarks | |
| Size | Length(headtotoe) width(sidetoside) anddepthincentimeters , , | |
| Woundbed | Tissuetypespresent(granulation slough necrotictissue/eschar epithelialtissue)andthepercentageofthe , , , | |
| bedcoveredbyeach | ||
| Edges | Attached unattached rolled(epibole) orundermined , , , | |
| Underminingand tunneling Exudate | Locationbyclockposition(12o'clocktowardthepatient'shead)anddepthincentimeters Amount color consistency odor , , , | 1 |
Table1.15—Woundassessmentanddocumentation(Continued)
| Parameter | Whattodocument |
|---|---|
| Periwoundskin | Color temperature edema induration maceration , , , , |
| Infection | Local:increasedpain erythemaextendingbeyondwoundedges warmth swelling purulentdrainage , , , , , |
| delayedhealing friablegranulationtissue Systemic(spreadinginfection):fever elevatedWBCcount , . , |
Table1.16—Dressingselectionbasics
| Dressing | Bestfor | Avoid/notes |
|---|---|---|
| Transparentfilm | Stage1protection superficialwounds IVsites;allows , , | Notfordrainingorinfectedwounds |
| visualization | ||
| Hydrocolloid | ShallowStage2orcleanStage3withlightexudate; | Notforinfectedorheavilydrainingwoundsor |
| promotesautolyticdebridement | fragileskin | |
| Hydrogel | Drywounds;donatesmoisture | Canmacerateperiwoundskin |
| Alginate/hydrofiber | Moderatetoheavyexudate;alginateaidshemostasis | Notfordrywounds;needsasecondarydressing |
| Foam | Moderateexudate;cushioningoverbonyprominences | Changewhensaturated |
| Negative-pressure | Largeordeepwounds dehiscedincisions;removes , | Notoverexposedvesselsororgans untreated , |
| woundtherapy | exudateandpromotesgranulation | osteomyelitis ormalignancyinthewound; , |
| monitorforbleeding |
Wound Healing
Healing occurs by primary intention (edges approximated, as in a closed surgical incision; minimal scarring), secondary intention (wound left open to fill with granulation tissue, as in pressure injuries), or tertiary intention (delayed primary closure after a contaminated wound is left open and cleaned). The four phases overlap.
➜
➜
➜
Immediately: vasoconstriction,
About 3–5 days: neutrophils and
About day 3 to week 3: collagen,
3 weeks to 2 years: collagen
platelet aggregation, clot
macrophages clear debris and
granulation, angiogenesis,
reorganizes; scar matures
bacteria
epithelialization, contraction
Table1.17—Phasesofwoundhealing
| Phase | Timing | Events |
|---|---|---|
| Hemostasis | Immediatelyafterinjury | Vasoconstrictionandplateletaggregationformaclot |
| Inflammatory | Typically3–5days | Neutrophilsandmacrophagescleardebrisandbacteria |
| Proliferative | About3daysto3 | Fibroblastsproducecollagentoformgranulationtissue;angiogenesiscreatesnew |
| weeks | vessels;epithelializationcoversthesurface;woundcontractionreducessize | |
| Remodeling | 3weeksto2years | Collagenreorganizestoincreasetensilestrength;thescarmaturesandmay |
| (maturation) | flattenandfade;maximumtensilestrengthreachesonlyabout80%oftheoriginal tissue |
Factors that impair healing: advanced age, malnutrition, diabetes, peripheral vascular disease, immunosuppression, medications such as corticosteroids, radiation therapy, smoking, and infection.
A heel with dry, stable black eschar and no signs of infection is left intact and offloaded: the eschar is a natural biological cover. A heel eschar that becomes boggy, fluctuant, draining, or surrounded by erythema is no longer stable and needs provider or wound-team evaluation for debridement.
Non-blanchable erythema on intact skin = Stage 1; exposed
Turn at least every 2 hours in bed; shift weight every 15
dermis = Stage 2; visible fat = Stage 3; bone, tendon, or
minutes in a chair; use 30-degree lateral tilt; float heels.
muscle = Stage 4.
Never massage bony prominences; never reverse-stage a
Purple or maroon intact skin = deep tissue pressure injury;
healing wound.
base hidden by slough or eschar = unstageable.
Healed tissue regains only about 80% of original tensile
Braden 6–23; ≤18 = at risk; lower is worse.
strength.
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