Definition
A.A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue
(NPUAP, 2016).
Incidence
A.Acute care: 0.4% to 38%.
B.Long-term care: 2.2% to 23.9%.
C.Home care: 0% to 17%.
Pathogenesis
A.Pressure ulcers occur when an area of tissue remains in surface contact for a period of time. This contact causes occlusion of microvascular vessels, which leads to tissue hypoxia and eventually may cause ischemia. Over time, a pressure ulcer is developed. The amount of time this takes is patient dependent and can be altered by physical and/or environmental factors.
Predisposing Factors
A.Acute illness.
B.Fecal/urinary incontinence.
C.Malnutrition.
D.Weight loss.
E.Failure or inability to offload:
1.For example, fracture, elevation of head of bed (HOB), lack of education, or noncompliance.
F.Chronic medical conditions.
G.Advanced age.
Common Complaints
A.Pain.
B.Bleeding.
C.Drainage.
Subjective Data
A.Ask the patient to describe the location and onset. What did he or she think may have caused the ulcer in the area? Was the onset sudden or gradual? How have the symptoms continued to develop?
B.Assess if the area is itchy or painful.
C.Assess for any associated drainage. Ask about the color and if any odor is noted.
D.Complete a drug history. Ask the patient if he or she is taking any steroids or anticoagulants.
E.Has the patient been treated for this location before? If so, describe treatments.
F.Determine whether the patient has attempted to treat this problem at home. If yes, ask with what.
G.Rule out any possible exposure to industrial or domestic toxins, or insect bites.
H.Assess for iodine and sulfa allergies before starting treatment.
Physical Exam
A.Check temperature, pulse, respirations, and blood pressure:
B.Inspect the pressure ulcer/injury:
1.Measure length × width × depth:
a.Undermining: Measure and note location, using the face of a clock to document site of undermining: for example, 12 o’clock, 3 o’clock, 6 o’clock, or 9 o’clock.
b.Tunneling: Measure and note location, using the face of a clock to document site of tunneling: for example, 12 o’clock, 3 o’clock, 6 o’clock, or 9 o’clock.
2.Describe the wound bed:
a.Tissue in the wound bed:
i.Necrotic tissue, slough tissue, granulation tissue, epithelial tissue (percentage of each should together equal 100%).
b.Drainage:
i.Amount:
•None, scant, moderate, copious.
ii.Color:
•Serous, purulent, yellow, serosanguineous, green.
c.Odor:
i.Odor present: Yes.
ii.Odor not present: No.
d.Periwound:
i.Intact.
ii.Not intact:
•Erythema, fever, induration, maceration, excoriation, calloused, epiboly.
Diagnostic Tests
A.Complete blood count (CBC).
B.Wound culture.
C.Wound biopsy.
D.X-ray.
E.MRI.
F.Bone scan.
Diagnosis: Staging Pressure Injuries/Ulcers
A.Deep-Tissue Pressure Injury (DTPI):
1.Intact or non-intact skin with persistent nonblanchable discoloration (purple, deep red, maroon) or epidermal separation revealing a blood-filled blister or darkened wound bed.
2.Changes in pain/temperature may precede changes in skin color. Discoloration may be difficult to detect in highly pigmented skin.
3.DTPI may be due to intense pressure and shear forces at the bone–muscle interface.
4.The wound may resolve without tissue loss, or rapid evolution may occur to reveal extent of damage.
5.If fascia, muscle, necrotic/subcutaneous/granulation tissue or other underlying structures are visible, this is likely a full-thickness pressure injury (Stage 3, 4, or unstageable).
6.Do not use DTPI staging to describe neuropathic, vascular, dermatologic, or traumatic conditions.
B.Stage 1 Pressure Injury:
1.Intact skin with nonblanchable, localized erythema. Discoloration may be difficult to detect in highly pigmented skin.
2.Changes in sensation, temperature, or firmness may precede visual changes.
3.Do not use Stage 1 to describe purple, deep red, or maroon discoloration; these may indicate DTPI.
C.Stage 2 Pressure Injury:
1.Partial-thickness loss of skin with exposed dermis.
2.The wound is moist, pink or red, viable, and may present as an intact or ruptured serum-filled blister.
3.Deeper tissues and adipose (fat) are not visible.
4.Eschar, slough, and granulation tissue are not present.
5.Stage 2 pressure injuries are the result of adverse microclimate or shear forces.
6.Do not use Stage 2 to describe the following:
a.Skin tears, burns, or abrasions.
b.Moisture-associated skin damage (MASD), including:
i.Incontinence-associated dermatitis (IAD).
ii.Intertriginous dermatitis (ITD).
iii.Medical adhesive-related skin injury (MARSI).
D.Stage 3 Pressure Injury:
1.Full-thickness loss of skin, with visible adipose.
2.Granulation tissue and epibole (rolled wound edges) are present.
3.Eschar and slough are present.
4.The extent of tissue damage varies by anatomical location; deep wounds may develop in areas of significant adiposity.
5.Undermining/tunneling may occur.
6.Muscle, tendon, ligament, cartilage, fascia and/or bone are not exposed.
7.Do not use Stage 3 if eschar or slough obscures the depth of tissue loss; this indicates an Unstageable Pressure Injury.
E.Stage 4 Pressure Injury:
1.Full-thickness loss of skin and tissue.
2.Muscle, tendon, ligament, cartilage, fascia, and/or bone are exposed or directly palpable.
3.Epibole (rolled wound edges), undermining, and/or tunneling often occur.
4.The extent of tissue damage varies by anatomical location.
5.Eschar or slough may be present. If either or both obscure the depth of tissue loss, this indicates an Unstageable Pressure Injury.
F.Unstageable Pressure Injury:
1.Full-thickness loss of skin and tissue.
2.Eschar or slough obscure the extent of tissue loss; removing these will reveal a Stage 3 or 4 Pressure Injury.
3.Do not soften or remove stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb.
G.Medical Device-Related Pressure Injury:
1.This is the result of using devices intended for diagnostic or therapeutic purposes.
2.The pressure injury generally conforms to the shape or pattern of the device.
3.The injury should be staged using the staging system.
H.Mucosal Membrane Pressure Injury:
1.Found on mucous membranes with a history of medical-device use at the injury’s location.
2.These ulcers cannot be staged due to the anatomy of the tissue.
Source: Adapted from National Pressure Ulcer Advisory Panel (NPUAP). (2016). NPUAP pressure injury stages. Retrieved from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/
Differential Diagnoses
A.Abscess.
B.Trauma.
C.Skin cancer.
D.Vascular ulcer.
E.Diabetic foot ulcers.
F.Dermatological disorder.
Plan
A.General interventions: Identify the cause of pressure and alleviate.
B.To debride: Normal saline (NS) cleanse, apply santyl and dressing change daily and as needed throughout.
C.To granulate an ulcer with scant drainage: NS cleanse, apply hydrogel and dressing change daily as needed.
D.To granulate an ulcer with moderate drainage: NS cleanse, apply calcium alginate and dressing change daily as needed.
Follow-Up
A.Follow up in 1 to 2 weeks to evaluate therapy.
B.See patients every 1 to 2 weeks until healing well; then may reduce to 2- to 4-week evaluation until complete closure.
Consultation/Referral
A.Consult or refer the patient to a wound care specialist:
1.Extensive ulcer that you are not comfortable with.
2.Patient with multiple medical comorbidities (especially diabetes).
3.Patient not responding to treatment of 2 to 4 weeks.
4.Ulcer showing decline on follow-up visit.
5.Infection present.
Individual Considerations
A.Patients at end of life may develop pressure ulcers related to the dying process. This type of ulcer is referred to as a Kennedy Terminal Ulcer. These patients are treated for comfort.
B.Geriatrics: Research suggests that pressure ulcers in the elderly population (especially those suffering dementia) appear to accelerate health deterioration, which leads to lower survival and higher mortality rates. Educating the patient and surrogates regarding good nutrition, fall prevention, skin care, and meticulous wound care techniques could help decrease pressure ulcer complications and increase survival time.