14.3 Pressure Injury Prevention and Management

Pressure injuries are a serious concern in healthcare, affecting patients with limited mobility or chronic conditions. Prevention and management are crucial aspects of maintaining skin integrity and promoting overall patient well-being.

Effective pressure injury care involves a multifaceted approach. This includes regular repositioning, proper skin care, nutritional support, and accurate wound assessment. Understanding risk factors and implementing tailored interventions are key to successful prevention and treatment.

Risk factors for pressure injuries

Patient characteristics and conditions

• Immobility affects patients with paralysis, prolonged bed rest, or limited mobility leading to increased pressure on specific body areas
• Advanced age increases susceptibility due to reduced skin elasticity, decreased subcutaneous fat, and diminished sensory perception
• Malnutrition and dehydration compromise skin integrity and reduce tissue resilience (inadequate protein intake, vitamin deficiencies)
• Incontinence and excessive moisture exposure increase skin vulnerability to breakdown and infection (urinary incontinence, profuse sweating)
• Chronic conditions elevate risk due to impaired circulation and sensation
  • Diabetes mellitus
  • Peripheral vascular disease
  • Spinal cord injuries

Medications and medical history

• Certain medications increase pressure injury risk by affecting skin integrity or reducing patient mobility
  • Steroids (prednisone)
  • Sedatives (benzodiazepines)
• Previous history of pressure injuries significantly increases the likelihood of developing new pressure injuries in the same or different locations
  • Scar tissue from healed pressure injuries has reduced elasticity and blood flow

Pressure injury prevention strategies

Repositioning and support surfaces

• Regular repositioning of immobile patients redistributes pressure and promotes blood flow to at-risk areas
  • Typically every 2 hours for bed-bound patients
  • Every 15-30 minutes for wheelchair-bound patients
• Utilization of pressure-redistributing support surfaces alleviates pressure on bony prominences
  • Specialized mattresses (alternating air mattresses)
  • Cushions (gel or foam wheelchair cushions)
• Proper positioning techniques
  • 30-degree lateral position to offload the sacrum
  • Pillows between knees and ankles to prevent pressure points

Skin care and moisture management

• Implementation of a comprehensive skin care regimen maintains skin integrity and prevents breakdown
  • Gentle cleansing with pH-balanced products
  • Moisturizing with emollients to hydrate skin
• Moisture management techniques protect the skin from excessive exposure
  • Using absorbent underpads (disposable or reusable)
  • Applying barrier creams (zinc oxide-based products)
• Regular skin assessments facilitate early identification of potential pressure injuries
  • Focus on high-risk areas (sacrum, heels, elbows)
  • Use of assessment tools (Braden Scale)

Nutrition and education

• Nutritional assessment and intervention support tissue health and wound healing
  • Adequate protein intake (1.2-1.5 g/kg body weight/day)
  • Sufficient calorie intake (30-35 kcal/kg body weight/day)
  • Vitamin and mineral supplementation as needed (Vitamin C, Zinc)
• Patient and caregiver education enhances compliance and promotes early detection of skin changes
  • Teaching proper positioning techniques
  • Instructing on daily skin inspection
  • Emphasizing importance of nutrition and hydration

Staging pressure injuries

Stage 1 and 2 pressure injuries

• Stage 1 pressure injuries present as non-blanchable erythema of intact skin
  • Changes in temperature, tissue consistency, or sensation may be present
  • May appear differently in darkly pigmented skin
• Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis
  • Present as a shallow open ulcer
  • May appear as an intact or ruptured serum-filled blister
  • No slough or bruising visible

Stage 3 and 4 pressure injuries

• Stage 3 pressure injuries characterized by full-thickness skin loss
  • Subcutaneous fat may be visible
  • No exposed muscle, tendon, or bone
  • Depth varies by anatomical location
• Stage 4 pressure injuries involve full-thickness skin and tissue loss
  • Exposed or directly palpable muscle, tendon, or bone
  • Often include undermining and tunneling
  • Depth varies by anatomical location

Special categories of pressure injuries

• Unstageable pressure injuries present as full-thickness skin and tissue loss
  • Base of the ulcer covered by slough or eschar
  • True depth of injury cannot be determined until debridement
• Deep tissue pressure injuries appear as persistent, non-blanchable discoloration
  • Deep red, maroon, or purple discoloration of intact or non-intact skin
  • May evolve into a thin blister over a dark wound bed
• Accurate staging requires thorough assessment of wound characteristics
  • Depth of tissue damage
  • Types of tissue present in the wound bed
  • Condition of surrounding skin

Care plans for pressure injuries

Assessment and wound management

• Comprehensive patient assessment informs development of personalized care plans
  • Medical history review
  • Nutritional status evaluation
  • Functional abilities assessment
• Selection of appropriate wound dressings based on wound characteristics
  • Exudate level (foam dressings for moderate to heavy exudate)
  • Presence of infection (silver-impregnated dressings)
  • Wound depth (alginate dressings for deep wounds)
• Implementation of pressure redistribution strategies
  • Tailored to patient's mobility status
  • Specific to pressure injury location (offloading devices for heel ulcers)

Pain management and nutrition

• Integration of pain management techniques enhances patient comfort and compliance
  • Pharmacological approaches (topical lidocaine, systemic analgesics)
  • Non-pharmacological approaches (repositioning, wound cleansing timing)
• Incorporation of nutritional interventions supports wound healing and overall health
  • Protein supplementation (oral protein supplements, modular protein powders)
  • Adequate hydration (30-35 mL/kg body weight/day)
  • Specific nutrient supplementation as needed (arginine, vitamin C)

Interdisciplinary collaboration and monitoring

• Collaboration with interdisciplinary team members addresses all aspects of patient care
  • Wound care specialists for complex wound management
  • Dietitians for tailored nutritional plans
  • Physical therapists for mobility and positioning strategies
• Regular reassessment and adjustment of the care plan
  • Monitoring wound healing progress (wound measurements, tissue type changes)
  • Evaluating changes in patient condition (mobility, nutritional status)
  • Adapting interventions based on evolving patient goals and preferences