Pressure Injuries

Introduction

Also known as bedsores, these ulcers are injuries to the skin and tissue due to prolonged periods of pressure. These injuries are most commonly seen in patients who have medical conditions that prevent them from changing positions or moving. For patients in wheelchairs, pressure injuries are often located on the tailbone, buttocks, shoulder blades, spine, backs of arms and legs. Patients who are bedridden can experience pressure injuries on the back of the head, shoulder blades, hips, lower back, tailbone, heels, ankles, and skin behind the knees.

Causes

  • Unrelieved pressure that disrupts blood supply
  • Friction from sliding in bed
  • Exposure to moisture
  • Limited mobility
  • Poor nutrition
  • Aging, fragile skin
  • Disease
  • Diabetes

Characteristics of Pressure Injuries

  • Location: Bony areas of the body like shoulder blades, spine, backs of arms and legs, back or sides of head, ears, lower back, hips, heels, ankles, buttocks, and tailbone.
  • With pressure ulcers, there are several staging systems that exist, the most widely used being the National Pressure Injury Advisory Panel (NPIAP), which classifies pressure injuries into four stages. It is important to note that pressure injuries do not always start at #1 and worsen. Deeper injuries can begin deteriorating the tissue before even presenting on the skin's surface.

Stage 1

  • Appearance: Intact skin, ulcer is not present yet.
  • Color: Red and discolored. Color may be very minimal depending on skin color.
  • Pain/Sensation: Patient may not feel any change in tenderness or pain, but some may report sensitivity to the area.
  • Exudate: Not present at this stage.
  • Size and Shape: Size will vary but depth will not apply as skin is still intact.

Stage 2

  • Appearance: Partial skin loss, blistering, and no subcutaneous tissue exposed. Includes intact or partially ruptured blisters.
  • Color: Pink to red base.
  • Pain/Sensation: May be warmer, cooler, firmer, softer or more tender.
  • Exudate: Minimal drainage may be present.
  • Size and Shape: Shallow, open sore.

Stage 3

  • Appearance: Skin loss, damage to subcutaneous tissue. No muscle or bone exposure.
  • Color: Redness around sore, yellowness.
  • Pain/Sensation: Increased pain and discomfort.
  • Exudate: More drainage will appear. Brownish-yellow pus could be present as well as greenish drainage.
  • Size and Shape: Size will vary, but crater- like depth. Depth will be dependent on location of injury.

Stage 4

  • Appearance: Full skin loss, extensive damage, necrosis, exposure to underlying muscle, tendon, and bone. Leathery or dead tissue may be present.
  • Color: Redness and depending on severity of wound, black and brown.
  • Pain/Sensation: Depending on the level of tissue damage, there could be a decreased level of sensitivity.
  • Exudate: Excessive drainage present.
  • Size and Shape: Size will vary, but crater- like depth. Depth will be dependent on location of injury.

Unstageable

  • Appearance: Base of the wound cannot be seen to determine the stage because it is covered by a layer of dead tissue.
  • Color: Yellow, grey, green, brown, or black.
  • Pain/Sensation: Pain can very from none to severe based on the level of damage.
  • Exudate: The amount and type of exudate can vary but will provide important clues about the wound's healing status and potential presence of infection.
  • Size and Shape: Size will vary but depth of damage cannot be determined because the wound base is covered by necrotic tissue.

Deep Tissue

  • Appearance: Wound is intact but tissues beneath the surface have been damaged. The injury often presents with a bruise-like appearance.
  • Color: Purple or dark red
  • Pain/Sensation: The affected area can be painful to the touch but depending on the level of tissue damage, there could be a decreased level of sensitivity.
  • Exudate: Because the skin is intact, drainage will often not be present. However, drainage can appear if pressure is applied to the injury.
  • Size and Shape: Size and shape will vary depending on the tissue affected.

Treating Pressure Injuries

The healing process of these injuries begins with lowering the pressure and friction to the wound. From there, we determine how deep the wound is, remove any damaged or dead tissue, and move forward with cleaning and dressing. In some cases, surgery may be recommended for patients with more serious pressure injury wounds.

Preventing Pressure Injuries

Below are a few ways you can work to prevent pressure injuries.

  • At home examination: Check body everyday from head to toe, paying careful attention to where pressure ulcers typically form. If signs of pressure ulcers are present, contact us immediately.
  • Avoid products that can be harsh on the skin such as exfoliants, strong soaps, etc.
  • Keep skin moisturized by using a gentle cream, ointment, emollient, and skin protectants and avoid taking a bath/showering everyday as this can dry out the skin too much.
  • Stay hydrated and eat enough calories to stay healthy but not gain too much weight.
  • Avoid clothes that apply excess pressure to the skin
  • Be sure to thoroughly clean and dry sensitive areas on the body, like groin, buttocks, chest, etc.
  • If possible, use mattresses that are filled with foam or gel or use a piece of soft foam between body parts that experience increased pressure.