Pressure ulcers, clinically referred to as pressure injuries, decubitus ulcers, or commonly known as bedsores, represent a significant healthcare concern. These injuries arise from sustained pressure on the skin, which compromises blood flow and oxygen supply to the underlying tissues. This deprivation leads to tissue ischemia, cell death, ulceration, and necrosis if not promptly addressed.
Understanding Pressure Injuries
Pressure injuries predominantly develop over bony prominences where there is minimal subcutaneous fat to cushion the skin against external surfaces. Common sites include the sacrum, coccyx, greater trochanter, heels, and lateral malleoli.
The most widely used classification system for pressure injuries is provided by the National Pressure Injury Advisory Panel (NPIAP), which stages injuries based on the depth of tissue damage:
- Stage 1: Characterized by intact skin with non-blanchable erythema, indicating altered microcirculation.
- Stage 2: Involves partial-thickness skin loss affecting the epidermis and/or dermis. It may present as an abrasion, blister, or shallow ulcer.
- Stage 3: Presents with full-thickness skin loss, where subcutaneous fat is visible, but not muscle, tendon, or bone. Depth varies by anatomical location.
- Stage 4: Full-thickness tissue loss with exposed muscle, tendon, bone, cartilage, or ligament. Undermining and tunneling are common in these ulcers.
- Unstageable: Full-thickness tissue loss where the extent of the damage cannot be determined because it is obscured by slough or eschar.
- Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration. This indicates damage to underlying soft tissue from pressure or shear forces.
Prevention is paramount in managing pressure injuries. Once developed, particularly stage 3 and 4 ulcers, they pose a significant risk for complications such as osteomyelitis and sepsis. While simple wound care may suffice for early stages, advanced pressure injuries often necessitate interventions like debridement, negative pressure wound therapy, hyperbaric oxygen therapy, or surgical procedures.
The Nursing Process and Pressure Injuries
Preventing and managing pressure injuries requires a collaborative healthcare approach. Nurses play a pivotal role in this process, from initial assessment to implementing preventive strategies and managing existing wounds. This involves meticulous nursing assessment, targeted interventions, and formulating relevant nursing diagnoses to guide care.
Nursing Assessment for Pressure Injuries
The nursing assessment is the cornerstone of effective care. It involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to understand the patient’s risk factors and the current status of any pressure injuries.
Reviewing Health History
1. Detailed Inquiry about the Pressure Injury:
When a pressure injury is present, gather specific details:
- Skin discoloration: Note the color, size, and location.
- Odor: Presence and nature of any foul odor.
- Discharge: Type, color, and amount of exudate.
- Sensation changes: Any reports of decreased sensation, pain, or discomfort at the site.
2. Identifying Potential Causes:
Assess factors contributing to pressure injury development:
- Skin and Mobility Status: Evaluate patient’s mobility level and any limitations.
- Medical Devices: Identify devices (e.g., diapers, IV lines, catheters) that could exert pressure.
- Moisture: Assess exposure to moisture from sweat, urine, or stool.
- Friction: Note potential for skin rubbing against surfaces like bed linens.
- Shear Force: Consider forces that cause tissue layers to slide over each other, damaging blood vessels.
3. Risk Factor Assessment:
Identify patients at higher risk:
- Age: Older adults are more susceptible due to thinner skin and reduced mobility.
- Mobility limitations: Bedridden or chair-bound individuals.
- Paralysis: Spinal cord injuries, stroke, or neuromuscular conditions.
- Incontinence: Urinary or fecal incontinence increases skin moisture.
- Nutritional status: Malnutrition or obesity can compromise skin integrity.
- Sensory perception: Impaired ability to sense pain or pressure.
4. Medical History Review:
Certain medical conditions increase pressure injury risk:
- Immobility-related conditions: Paraplegia, quadriplegia, spina bifida.
- Sensory perception deficits: Neuropathies, cognitive impairments.
- Circulatory disorders: Peripheral vascular disease, diabetes.
Note: Hospital length of stay is a significant factor; longer stays increase pressure injury incidence.
5. Medication Review:
Be aware of drug-induced pressure ulcers (DIPU), particularly associated with psychiatric medications in the elderly.
6. Socio-environmental Factors:
Consider the patient’s living situation and support system. Stage 4 pressure injuries can indicate neglect, especially in nursing homes or home care settings. Assess caregiver capabilities and provide education as needed.
7. Surgical History:
Prolonged surgeries and post-operative immobility are significant risks. Pressure injuries can develop within hours of immobility.
Alt text: A nurse carefully assesses a pressure ulcer on a patient’s sacrum, documenting size and characteristics for effective wound management.
Physical Examination
1. Comprehensive Pressure Ulcer Assessment:
Thoroughly describe the pressure injury:
- Size: Measure length, width, and depth in centimeters.
- Exudate: Note the amount, color, and consistency.
- Odor: Describe any odor present.
- Undermining and Tunneling: Assess for tissue destruction extending under the skin edges (undermining) and sinus tracts (tunneling).
- Necrotic Tissue: Identify and describe slough (yellow or white, stringy tissue) and eschar (black or brown, hard tissue).
- Healing Status: Look for granulation tissue (red, cobblestone appearance) and epithelialization (new skin growth).
- Wound Margins and Periwound Skin: Assess the condition of the skin around the ulcer for redness, maceration, or induration.
2. Pressure Injury Staging:
Accurately stage the pressure injury using the NPIAP classification system. Correct staging is crucial for monitoring progression and treatment effectiveness.
3. Mental Status Evaluation:
Assess the patient’s ability to communicate needs and discomfort, which is vital for preventative care.
4. Neuromuscular and Mobility Status:
Evaluate sensory perception and motor function. Conditions like spinal cord injuries impair sensation and mobility, increasing pressure injury risk.
5. Braden Scale Assessment:
Utilize the Braden Scale, a validated tool for pressure injury risk assessment. It evaluates:
- Sensory Perception: Ability to respond to pressure-related discomfort.
- Moisture: Degree of skin exposure to moisture.
- Activity: Level of physical activity.
- Mobility: Ability to change and control body position.
- Nutrition: Usual food intake pattern.
- Friction and Shear: Assistance required for movement and sliding in bed or chair.
Scores from the Braden Scale guide the intensity of preventive interventions.
Diagnostic Procedures
1. Blood Workup:
Laboratory values can provide insights into factors affecting pressure injury development and healing:
- White Blood Cell Count (WBC): Elevated WBC indicates inflammation or infection.
- Hemoglobin: Low levels suggest reduced oxygen delivery to tissues.
- Platelet Count: Low platelets can impair wound healing processes.
- Albumin: Low albumin indicates protein deficiency, hindering wound repair.
- Glucose: Elevated glucose can impair wound healing.
2. Wound Culture:
Obtain wound cultures from pressure ulcers with drainage or signs of infection to identify pathogens and guide antibiotic therapy.
3. Tissue Biopsy:
Consider biopsy for non-healing pressure ulcers to rule out osteomyelitis or malignancy.
4. Imaging Studies:
MRI or CT scans may be necessary if osteomyelitis is suspected to assess bone involvement.
Nursing Interventions for Pressure Injuries
Nursing interventions are crucial for both preventing pressure injuries and managing existing ones.
Pressure Ulcer Prevention Strategies
1. Regular Repositioning:
Implement a turning schedule, repositioning patients at least every two hours. Delegate turning schedules to assistive personnel. Encourage activity as tolerated, including range of motion exercises and ambulation.
2. Skin Hygiene and Moisture Management:
Maintain clean and dry skin. Use moisture barrier creams to protect skin from incontinence. Consider fecal or urinary diversion devices if needed.
3. Pressure-Relieving Support Surfaces:
Utilize specialty mattresses, cushions, foam wedges, and heel protectors to offload bony prominences.
4. Friction and Shear Reduction:
Use transfer sheets to minimize friction during repositioning. Keep the head of the bed as low as possible to reduce shear forces from sliding down.
5. Hydration and Nutrition Optimization:
Ensure adequate protein and nutrient intake to support skin health and wound healing. Maintain hydration for cell function and skin elasticity.
6. Minimize Pressure from Devices:
Keep medical devices (catheters, IV lines) from directly pressing on the skin. Ensure linens and clothing are smooth and wrinkle-free.
7. Patient and Caregiver Education:
Educate patients and caregivers on pressure injury prevention:
- Adhering to repositioning schedules.
- Maintaining skin hygiene.
- Using support surfaces.
- Recognizing early warning signs of skin breakdown.
Alt text: A nurse demonstrates proper technique while turning a bedridden patient to prevent pressure injuries and promote skin integrity.
Treatment of Existing Pressure Ulcers
1. Pressure Relief and Protection:
For Stage 1 pressure injuries, focus on offloading pressure through frequent repositioning and pressure-relieving devices. Apply protective dressings like Mepilex Border to sacral or heel areas.
2. Wound Dressing Selection:
Choose dressings based on wound characteristics (drainage, infection):
- Infected, non-draining wounds: Silver dressings, medical-grade honey, foam.
- Infected, draining wounds: Alginate, silver, gauze, foam.
- Non-infected, non-draining wounds: Hydrogel.
- Non-infected, draining wounds: Alginate, hydrocolloid, gauze, foam.
3. Debridement Preparation:
Prepare for debridement to remove necrotic tissue, which may involve moist dressings, enzymatic ointments, or surgical debridement by a wound care specialist.
4. Negative Pressure Wound Therapy (NPWT):
Consider wound VAC for Stage 3 or 4 pressure ulcers to remove exudate, promote granulation, and wound closure.
5. Pain Management:
Administer analgesics as prescribed, especially before wound care procedures if the patient experiences pain.
6. Surgical Intervention:
Surgical debridement, skin grafts, or flap reconstruction may be necessary for complex wounds.
7. Hyperbaric Oxygen Therapy:
Consider hyperbaric oxygen therapy to enhance tissue oxygenation and promote healing in chronic, non-healing wounds.
8. Dietitian Consultation:
Consult a dietitian to optimize nutrition and hydration, ensuring adequate protein, macronutrients, and micronutrients for wound healing.
9. Wound Care Specialist Referral:
Refer complex or chronic pressure ulcers to a certified wound care nurse or specialist for advanced management.
Pressure Injury Nursing Diagnoses and Care Plans
Nursing diagnoses provide a framework for planning and delivering patient-centered care. For pressure injuries, common nursing diagnoses include Impaired Physical Mobility, Impaired Skin Integrity, Impaired Tissue Integrity, Ineffective Peripheral Tissue Perfusion, and Risk for Infection.
Impaired Physical Mobility
Patients with limited mobility are at high risk for pressure injuries due to their inability to relieve pressure independently.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Paralysis
- Prescribed bed rest
- Decreased muscle strength
- Contractures
- Pain
- Neuromuscular conditions
- Cognitive impairment
- Obesity
As evidenced by:
- Limited range of motion
- Inability to reposition self
Expected Outcomes:
- Patient will use assistive devices to improve repositioning.
- Patient will verbalize pressure injury prevention strategies.
- Patient will remain free from pressure injury development.
Assessments:
- Mobility Assessment: Evaluate range of motion, strength, and ability to reposition.
- Caregiver Understanding: Assess staff or family understanding of proper turning and skin care techniques.
Interventions:
- Assistive Devices: Provide trapeze bars, side rails to aid in repositioning.
- Support Surfaces: Use wedges, pillows, heel protectors, and air mattresses to protect bony prominences.
- Pain Management: Pre-medicate for pain before repositioning; manage chronic pain for improved mobility.
- Education on Inspection Areas: Educate patients and caregivers on areas prone to pressure and shear.
- Promote Activity: Assist with chair transfers and ambulation to relieve pressure and improve circulation.
- Turning Schedule: Implement and adhere to a 2-hour turning schedule for bed-bound patients; remind chair-bound patients to reposition every 15 minutes.
Impaired Skin Integrity
Compromised skin is a primary risk factor for pressure injuries.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Poor nutritional status
- Edema
- Impaired circulation
- Neuropathy
- Moisture/Incontinence
- Friction/Shear
- Immobility
As evidenced by:
- Pain or numbness in affected area
- Skin color changes (erythema, blanching, bruising)
- Skin disruption (breakdown, excoriation)
- Pus or bloody drainage
Expected Outcomes:
- Pressure ulcer resolution within 30 days.
- Patient demonstrates preventive measures for skin integrity.
- Pressure ulcer improvement (reduced size, no drainage).
Assessments:
- Skin Assessment: Conduct skin assessments every shift, using the Braden Scale.
- Pressure Ulcer Staging: Accurately stage any existing pressure ulcers.
- Risk Factor Identification: Identify contributing factors like age, chronic conditions, cognition, nutrition.
Interventions:
- Wound Care Collaboration: Involve wound care nurses early for any skin breakdown.
- Nutritional Support: Encourage nutrition and hydration, potentially including enteral or parenteral nutrition.
- Skin Hygiene: Maintain clean, dry skin; provide frequent perineal care and linen changes for incontinent patients.
- Wound Care Implementation: Follow prescribed wound care orders, including cleansing and dressings.
Impaired Tissue Integrity
Indicates deeper tissue damage associated with more severe pressure injuries.
Nursing Diagnosis: Impaired Tissue Integrity
Related to:
- Pressure injury
- Delayed wound healing
- Infection
- Poor circulation
- Impaired mobility
- Poor nutrition
As evidenced by:
- Pain
- Redness
- Bleeding
- Warmth
- Tissue damage
Expected Outcomes:
- Patient demonstrates tissue protection and healing interventions.
- Pressure ulcer size reduction.
Assessments:
- Pressure Injury Staging: Monitor and document the stage of the pressure injury.
- Etiological Factors: Assess contributing factors to impaired tissue integrity.
- Wound Measurement: Monitor and document wound size and depth regularly.
Interventions:
- Frequent Repositioning: Reposition every 2 hours, avoiding pressure on the injury site.
- Debridement: Prepare for and perform debridement as indicated.
- Pressure-Relieving Devices: Utilize specialized mattresses and cushions.
- Multidisciplinary Consultation: Consult wound care nurses, dietitians, and PT/OT for holistic care.
Ineffective Peripheral Tissue Perfusion
Compromised blood flow increases pressure injury risk and impairs healing.
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion
Related to:
- Diabetes mellitus
- Infection
- Circulatory compromise
- Smoking
As evidenced by:
- Diminished peripheral pulses
- Altered motor function
- Skin discoloration
- Pain
- Edema
- Delayed wound healing
Expected Outcomes:
- Patient demonstrates adequate tissue perfusion (palpable pulses, normal skin color, wound healing).
- Patient verbalizes understanding of factors affecting perfusion.
Assessments:
- Peripheral Pulse Assessment: Monitor peripheral pulses for strength and presence.
- Tissue Perfusion Symptoms: Assess for pain, skin discoloration, delayed capillary refill, paresthesia.
Interventions:
- Routine Skin Assessments: Frequent skin assessments for patients at risk for poor perfusion.
- Promote Movement: Encourage movement within patient capabilities; consult PT for exercise plans.
- Caution with Heat/Cold: Avoid direct heat or cold application to pressure ulcers due to sensory deficits.
- Risk Factor Education: Educate patients on risk factors like smoking and diabetes that affect perfusion.
Risk for Infection
Pressure injuries create a portal of entry for pathogens.
Nursing Diagnosis: Risk for Infection
Related to:
- Broken skin integrity
- Immunocompromised status
- Poor hygiene
- Incontinence
As evidenced by:
Risk diagnosis is not evidenced by signs and symptoms.
Expected Outcomes:
- Patient remains free from wound infection signs (redness, drainage, odor, warmth).
- Patient remains free from systemic infection (normal temperature, WBC).
- Wound dressings remain intact.
Assessments:
- Infection Monitoring: Monitor for local (drainage, odor, redness) and systemic (fever, tachycardia) infection signs.
- Wound Cultures: Obtain cultures for suspected wound infections.
- Lab Work Review: Monitor WBC count and other labs (protein, glucose) influencing wound healing.
Interventions:
- Antibiotic Administration: Administer prophylactic or therapeutic antibiotics as ordered.
- Hand Hygiene: Strict hand hygiene before wound care.
- Dressing Integrity: Ensure dressings are intact, clean, and dry; change as needed.
- Infection Prevention Education: Educate patients and caregivers on home infection prevention.
References
- National Pressure Injury Advisory Panel (NPIAP) – https://npiap.com/
- European Pressure Ulcer Advisory Panel (EPUAP) – https://epuap.org/
- Registered Nurses’ Association of Ontario (RNAO). (2016). Pressure injuries (pressure ulcers): Prevention and management (3rd ed.). Toronto, ON: Registered Nurses’ Association of Ontario.
- Agency for Healthcare Research and Quality (AHRQ). (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu5.htm
