Wound Pressure Injury Management


Article Author:
Ahmad Al Aboud


Article Editor:
Biagio Manna


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
9/10/2019 10:59:15 PM

Introduction

Wound pressure injuries have been given various names over the last several years. In the past, they were referred to as pressure ulcers, decubitus ulcers, or bed sores; and now they are most commonly termed "pressure injuries." Pressure injuries are defined as the breakdown of skin integrity due to some types of unrelieved pressure. This can be from a bony area on the body coming into contact with an external surface which leads to pressure injury. These wounds represent the destruction of normal structure and function of the skin and soft tissue through a variety of mechanisms and etiologies. The wound healing process is affected by various factors including infection, the presence of chronic diseases like diabetes, aging, nutritional deficiency like vitamin C, medications like steroids, and low perfusion of oxygen and blood flow to the wound in cases of hypoxia and cold temperature. Pressure ulcers result from long periods of repeated pressure applied to the skin, soft tissue, muscle, and bone. In pressure ulcers, the external pressure exceeds capillary closing pressure.[1][2][3]

Anatomy

Elderly and bed-bound individuals are more prone to developing pressure (decubitus) ulcers. The hip and buttock region accounts for approximately two-thirds all pressure ulcers. Also, the skin underneath the nasogastric or endotracheal tubes might be affected by pressure ulcers. They are slightly more predominant in females than males. Decubitus ulcers are caused by a prolonged period of repeated friction and shearing pressure of the skin overlying the bony prominences along with some of the following intrinsic causes:

  • Loss of skin fragility
  • Decreased blood flow
  • Loss of muscle volume
  • Spinal cord injuries
  • Nutritional insufficiency
  • Moisture due to fecal and/or urinary incontinence

Understanding how a pressure injury happens requires a review of the basic layers of the skin. The epidermis is the most superficial layer. Just below the epidermis is the dermis, and then right below the dermis is the capillary bed which feeds, perfuses, and supplies the dermis and epidermis. Below the capillary bed is the fatty subcutaneous tissue, followed by muscle and then bone. Hence, in a patient who is sitting in the chair for a really long time, the coccyx bone which is obvious the bony prominence is going to place the patient at risk for developing a pressure injury by exerting upward pressure on bottom skin layers. In addition, there is the external hard surface of the chair that can also place pressure on the skin and bony prominences. If the pressure is prolonged, it can compromise blood supply to the skin.

It is very important to avoid friction and shear force injuries. These injuries may occur when the patient is sliding down in the bed. For example, when the coccyx bone is moving upwards and the skin is moving downward (i.e., the two forces move in opposite direction), the middle layer which supplies and perfuses the dermis and epidermis may tear, leading to decreased perfusion and eventually resulting in a pressure injury. There are various stages of pressure injury, all of which classify the injury based on the depth of skin injury. Pressure ulcers are categorized into four stages:

  • Stage 1: just erythema of the skin
  • Stage 2: erythema with the loss of partial thickness of the skin including epidermis and part of the superficial dermis
  • Stage 3: full thickness ulcer that might involve the subcutaneous fat
  • Stage 4: full thickness ulcer with the involvement of the muscle or bone

The most common sites for pressure injuries include the sacrum (tailbone) followed by the heels, trochanter (hip bone), and the ischium (sitting erect bone), especially in paraplegic patients.[4][5][6]

Indications

Before mentioning ways to treat pressure ulcers, it is important to discuss ways to prevent them; ironically, the ways to prevent ulcers are also ways to treat them. All hospitals use screening tools on admission to determine the risk of pressure sores.

Braden Scale

The Braden scale is a widely used screening too to determines the patients who are at risk. This assessment tool consists of six categories:

  1. Sensory perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction/shear

Number one through four on these categories indicates that there is no potential problem; however, receiving a one means the patient is at great risk. Friction and shear is the sixth category which often can disrupt skin integrity. The highest Braden score one can achieve is 23, and the lowest is 6; the lower the number, the higher the risk of developing an ulcer.

Norton Scale

The Norton scale is also used as an assessment tool for patients who are at great risk of developing pressure ulcers. This scale relies on these factors:

  1. Physical condition
  2. Mental condition
  3. Activity 
  4. Mobility
  5. Continence

Each category has four grades (1-4), number 4 means the patient is healthy and number 1 means the patient is at great risk. The highest possible score is 20, and the lowest possible score is 5. The onset of risk = 16 or below; high risk = 12 or below.

Other simple prevention measures include proper nutrition, pressure relieving repositioning, hygiene and moisture control, special mattresses, and topical skin care. Adequate nutrition is needed for tissue metabolism and is necessary for the prevention and healing of pressure ulcers. The patient must be provided with sufficient calories, fluid, protein, vitamin C, and zinc. For those who are not able to eat, a feeding tube may be necessary, otherwise wound healing will not take place.

Contraindications

The use of harsh soaps, irritant solutions, aggressive debridement, and hard mattresses should be avoided in treating patients with decubitus ulcers because it might aggravate the situation and lead to delayed healing, especially in elderly bed-bound patients.

Equipment

Different risk assessment tools that have been developed; the most widely used is the Braden and Norton Scales discussed above.

Personnel

The wound management team is responsible for taking care of any patient with pressure sores. This team usually includes the primary attending, dermatologist and/or plastic surgeon, nurse, nurse assistant, dietitian, and physical therapist. Daily skin check-up is required, especially for patients who are at a high risk for skin breakdown based on the Braden and Norton scales.

Technique

Proper repositioning is essential in maintaining skin integrity and is needed in patients who are unable to do this for themselves. Pressure, friction, and shear forces should be avoided during positioning. The most effective way of repositioning is to move the patient every 2 hours so that the ischemic areas can recover. This can be done with the use of pillows or wedges to keep the patient on their side and placing pillows between their legs and under their calves helps take pressure off their back, buttocks, medial aspect of the knees, and heels. Hygiene and moisture reduction are very important, especially for patients who are incontinent; excess moisture is known to cause the skin to break down, and the patient must always be kept dry. This job falls on the nursing assistants who are responsible for making sure the patient is clean at all times. If patients develop skin breakdown due to moisture, the nurse is at fault for not properly delegating and overseeing the nursing assistants.

An air mattress is a pressure-relief device that is constantly being inflated with air to prevent skin breakdown and used to prevent ulcers in patients at high risk or in patients with existing ulcers. If the patient has a Braden score of 12 or less, they should be placed on an air mattress, and a proper skin assessment should be done at least once a day or every shift. For at-risk patients, the nurse must always make sure the patient is clean and dry. Soaps, alcohol-based lotions, and hot water should be avoided when bathing a patient because these can cause the skin to become dry and leave an alkaline residue which discourages the growth of normal skin bacteria. Initiating weekly rounds is a great way to assess the wound and skin integrity. Working as a team, the wound care doctor, nurse, and nursing assistant should fully assess all patients admitted to the floor. Bedsores are evaluated and proper care determined according to need. To prevent and treat pressure ulcers, it is important to know what they are and how to assess and treat them with help from the entire wound team. Debridement of necrotic tissues will accelerate healing by preventing the growth of pathogenic organisms.

Several reports on the therapeutic efficacy of laser sessions, ultrasound, recombinant platelet-derived growth factors, and hyperbaric oxygen have shown some improvement in the healing of pressure injuries, especially stage III and above; however, more clinical trials are needed.

Complications

Even with good nursing care in a high-standard medical facility, complications of pressure injuries still occur and can be life-threatening. All stages of pressure ulcers are prone to complications, especially stage III and stage IV. These complications include cellulitis, osteomyelitis, necrotizing fasciitis, gas gangrene, and septicemia.

Clinical Significance

Pressure ulcers are primarily diagnosed clinically. It is helpful to look at other lesions on the individual’s skin to see the body's response to physical trauma. It is also easier to diagnose decubitus ulcers by inspection and palpation, which usually reveals erythematous macerated texture. History should also include assessing comorbid conditions like diabetes and spinal injuries. Prevention and treatment of pressure ulcers are very important to avoid the life-threatening complications mentioned.

Enhancing Healthcare Team Outcomes

The primary goal is to prevent decubitus ulcers through various means including the use of air-fluidized or foam mattresses, improving the nutritional status of the patients, proper placing of patients in bed, changing position frequently, and treatment of the underlying diseases. A treatment plan involves the removal of all devitalized tissue that may serve as a reservoir for bacterial contamination (debridement). Also, it involves dressing by utilizing hydrogels, hydrocolloids, or saline-moistened gauze to enable granulation tissue to grow and the wound to heal. Treatment of underlying infection by topical or systemic antibiotic medications might be needed to help in the healing process, but tissue culture should be obtained before selecting the accurate drug. Pain and discomfort can be controlled by analgesics. A dietary consult should be made to ensure that the patient is receiving adequate calories. When possible, the patient should be out of bed to chair, and physical therapy should be consulted for ambulation and/or exercise. Wound care specialty trained nurses should assist in dressing changes, debridement of wounds, and provide close followup care. The nurses should also assist the clinician in the education of the patient and family. Decubitus ulcers are very difficult to treat, it is crucial that the nurses and clinicians work together as an interdisciplinary team to provide the very best care including treatment, monitoring, and followup care. [7][8][9] (Level V)

Outcomes

Pressure injuries are common and often result in a prolonged hospital stay and increased healthcare costs. Each year nearly 60,000 people die because of complications associated with pressure wounds. The two most common causes of death linked to pressure injuries are amyloidosis and renal failure. Infection is another major complication of pressure injuries, which often lead to osteomyelitis and chronic non-healing wounds. Unfortunately, despite awareness of the problem, the rates of pressure wounds remain high in long-term care facilities and nursing homes, where a lack of staff and optimal care is not always possible.[10][11](Level V) 


  • Image 6856 Not availableImage 6856 Not available
    Contributed by Ahmad Al Aboud, MD
Attributed To: Contributed by Ahmad Al Aboud, MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Wound Pressure Injury Management - Questions

Take a quiz of the questions on this article.

Take Quiz
A nursing home patient with a partial thickness loss of epidermis and dermal tissue, which is 4 x 4 cm, is felt to have a pressure ulcer. The skin overlying the ulcer is red and partially torn, but there is no fluid buildup. What stage is this?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient who has suffered a stroke and has been bedridden for the past 4 years develops a stage four pressure injury at the sacrum with visible bone. She was recently diagnosed with metastatic colon cancer. What is the best treatment for her pressure injury?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is an important factor in pressure ulcer healing?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A full-thickness pressure injury with exposed bone is at what pressure injury stage?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most appropriate dressing for a stage 2 pressure injury?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about pressure ulcers is false?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about pressure ulcers is false?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the followings is not a predisposing factor for developing a pressure ulcer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is useful in the treatment of an infected pressure ulcer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Wound Pressure Injury Management - References

References

Cowan L,Garvan C,Rugs D,Barks L,Chavez M,Orozco T, Pressure Injury Education in the Department of Veterans Affairs: Results of a National Wound Provider Cross-sectional Survey. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society. 2018 Sep/Oct     [PubMed]
Tappen RM,Newman D,Huckfeldt P,Yang Z,Engstrom G,Wolf DG,Shutes J,Rojido C,Ouslander JG, Evaluation of Nursing Facility Resident Safety During Implementation of the INTERACT Quality Improvement Program. Journal of the American Medical Directors Association. 2018 Oct     [PubMed]
Catania QN,Morgan M,Martin R, Activity-Based Restorative Therapy and Skin Tears in Patients with Spinal Cord Injury. Advances in skin     [PubMed]
Dincer M,Doger C,Tas SS,Karakaya D, An analysis of patients in palliative care with pressure injuries. Nigerian journal of clinical practice. 2018 Apr     [PubMed]
Delmore B,Ayello EA,Smart H,Sibbald RG, Assessing Pressure Injury Knowledge Using the Pieper-Zulkowski Pressure Ulcer Knowledge Test. Advances in skin     [PubMed]
Li D,Mathews C,Zhang F, The characteristics of pressure injury photographs from the electronic health record in clinical settings. Journal of clinical nursing. 2018 Feb     [PubMed]
Rosen T,Reisig C,LoFaso VM,Bloemen EM,Clark S,McCarthy TJ,Mtui EP,Flomenbaum NE,Lachs MS, Describing visible acute injuries: development of a comprehensive taxonomy for research and practice. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention. 2017 Oct     [PubMed]
Edsberg LE,Black JM,Goldberg M,McNichol L,Moore L,Sieggreen M, Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society. 2016 Nov/Dec     [PubMed]
Tadiparthi S,Hartley A,Alzweri L,Mecci M,Siddiqui H, Improving outcomes following reconstruction of pressure sores in spinal injury patients: A multidisciplinary approach. Journal of plastic, reconstructive     [PubMed]
Odgaard L,Aadal L,Eskildsen M,Poulsen I, Nursing Sensitive Outcomes After Severe Traumatic Brain Injury: A Nationwide Study. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses. 2018 Jun     [PubMed]
Stojmenski S,Merdzanovski I,Gavrilovski A,Pejkova S,Dzokic G,Tudzarova S, Treatment of Decubitis Ulcer Stage IV in the Patient with Polytrauma and Vertical Share Pelvic Fracture, Diagnosed Entherocollitis and Deep Wound Infection with {i}Clostridium Difficile{/i} with Combined Negative Pressure Wound Therapy (NPWT) and Faecal Management System: Case Report. Open access Macedonian journal of medical sciences. 2017 Jun 15     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Elder Adult Care. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Elder Adult Care, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Elder Adult Care, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Elder Adult Care. When it is time for the Nurse-Elder Adult Care board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Elder Adult Care.