Skin and Wound Care

Pressure Injury

Pressure injury: localized damage to the skin and/or underlying 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 conditions of the soft tissue (NPAUP, 2016).

 Tips for pressure ulcer prevention

Nova Scotia Health Authority, 2016.

Staging

Only use NPUAP's 6 stages to describe pressure injuries, not other wound etiologies.

  •  Medical Device-related Pressure Injury: This describes an etiology. Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.
  • Mucosal Membrane Pressure Injury: Mucosal membrane pressure injuries are found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these ulcers cannot be staged.
  • Do not reverse stage: NPUAP pressure injury staging describes the depth of tissue damage due to pressure. It does not describe healing tissue. Do not reverse stage using NPUAP pressure injury staging (i.e., a Stage 4 pressure injury cannot become a Stage 3, Stage 2, and/or subsequently Stage 1. When a Stage 4 injury has healed, it should be classified as a healed Stage 4 pressure injury.)
  • Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.
  • Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
  • Colour changes do not include purple or maroon discolouration; these may indicate deep tissue pressure injury.1
  • Partial-thickness loss of skin with exposed dermis.
  • The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
  • Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present.
  • These injuries commonly result from adverse microclimate and shear in the skin over the pelvis or in the heel.
  • This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).1
  • Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.
  • Slough and/or eschar may be visible.
  • The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.
  • Undermining and tunnelling may occur.
  • Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed.
  • If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.1
  • Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in ulcer.
  • Slough and/or eschar may be visible.
  • Epibole (rolled edges), undermining, and/or tunnelling often occur.
  • Depth varies by anatomical location.
  • If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.1
  • Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
  • If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.
  • Stable eschar (i.e., dry, adherent, and intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.1
  •  Intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discolouration, or epidermal separation revealing a dark wound bed or blood-filled blister.
  • Pain and temperature change often precede skin colour changes. Discolouration may appear differently in darkly pigmented skin.
  • This injury results from intense and/or prolonged pressure and shear forces at the bone/muscle interface.
  • The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.
  • If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, Stage 3, or Stage 4).
  • Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.1
There may not be visible erythema (blanching or non-blanching), but colour changes that are darker than the surrounding area; this can present as purplish or bluish in colour. 
  • Colour changes remain unchanged when pressure is applied.
  • Colour over a bony prominence is different than usual skin colour.
  • If the patient has had a previous pressure injury, the skin may be light in colour over the healed area.
As colour changes may be subtle, it’s important to assess for:
  • Tissue consistency - Palpate both bony prominence and surrounding area to feel for any changes:
    • Edema: may appear taut and shiny, feels firm  
    • Bogginess: soft and “squishy” feeling 
  • Temperature difference - Compare area to surrounding skin for any difference:
    • Warmer: inflammation happening in localized area 
    • Cooler: sign of tissue devitalization (pressure injury progressing to deeper tissues)
  • Patient perception of sensation (pain or itching) over a bony prominence or a medical device as compared to surrounding skin
Any assessed skin changes over a bony prominence or under a medical device would indicate the presence of a pressure injury.

Tips for assessing:

  • Moisten the skin a little.
  • Avoid direct or fluorescent light; use natural light whenever possible.

Prevention

  • Use the Braden Scale to guide development of a care plan.3
  • Based on the scores for the categories on the Scale, apply specific interventions to mitigate risks.

Interpreting results:

Level of Risk Scoring Score
At Risk 15-18
Moderate 13-14
High Risk 10-12
Very High Risk 9 or less

Table adapted from NSHA's Pressure Ulcer Risk Assessment and Documentation Tool (Braden).

NPUAP has many resources to support clinical practice for preventing and managing Pressure Injuries:

Pressure Redistribution4-9:

  • Support surface (i.e., mattress, seat cushions).
  • Turn Q2hours or more frequently, depending on client's needs.
  • Use pillows and position assists.
  • Protect heels from surface of bed.
  • Consult OT for equipment needs.
  • Consult PT if there are mobility issues.
  • Create a repositioning and walking schedule.

Moisture4-9:

  • Address cause of incontinence.
  • Keep skin clean and free of incontinence.
  • Establish a toileting program.
  • Use barrier cream to protect skin when appropriate.

Nutrition4-10:

  • Maintain hydration.
  • Promote adequate nutrition.
  • Consult dietitian, if necessary.

Friction and Shear4-9:

  • Maintain head of bed below 30 degrees when possible.
  • Raise foot of bed 10-20 degrees unless contra-indicated.
  • Use lift/slider sheets.
  • Protect heels and elbows from friction.
  • Raise foot of bed prior to head of bed to ensure client does not slip down (shearing forces).

Management

Pressure Injury management includes a comprehensive client and wound assessment to guide the creation of an individualized care plan, with the appropriate referrals to the multidisciplinary team.3-9,11-14

Care plans need to encompass the principles of wound healing:

 Patient-centered concerns3-9,11-14:

  • Quality of life (pain, psychosocial, and socioeconomic concerns)
  • Co-morbidities
  • Medications
  • Nutrition

 Treating the cause of the wound3-9,11-14:

  • Pressure redistribution: consider all of the surfaces that a client spends the majority of their time on (i.e., mattress, wheelchair, toilet seat, etc.)
    • Create a repositioning schedule
  • Moisture: if this is a contributing factor, implement interventions to eliminate or decrease the exposure to excessive moisture
  • Friction and Shear forces: intervention to decrease the effects of these

Determine healability to distinguish care goals (healable, non-healable, or non-healing) 3-9,11-14

Local wound care3-9,11-14:

  • Moisture management
  • Bacterial balance
  • Debridement of non-viable tissue
  • Peri-wound skin  

Resources

Reference Toolkit

About

This resource binder was developed as part of a quality improvement initiative led by the Department of Health and Wellness Continuing Care branch in partnership with the Nova Scotia Health Authority Provincial Wound Prevention and Management Program. It is a compilation of best-practice recommendations for the prevention and management of pressure injuries. The purpose of this resource is to support continuity of care, enhance knowledge, and build capacity to address pressure injury prevention and management in long-term care facilities.

Braden & Pressure Staging Presentation

About

This presentation covers assessment of pressure injuries, grading using the Braden Scale, and prevention strategies.

Questions? Email provincialwoundprogram@nshealth.ca. 

Patient Experiences

  Marg

Nova Scotia Health Authority, 2016.

 Carl

Nova Scotia Health Authority, 2016.

 Jackie

Nova Scotia Health Authority, 2016.

 Sandra

Nova Scotia Health Authority, 2016.

1. National Pressure Ulcer Advisory Panel (NPUAP) website. www.npuap.org; Accessed July 2018

2. Braden, B.; Bergstrom, N. (2017) Permission to Use Braden Scale in Nova Scotia Health Authority and the Long Term Care Sector; Prevention Plus Omaha, NE.

3. British Columbia Provincial Nursing Skin and Wound Committee. Braden Scale Intervention Guide-Adults 2017. [cited 2018 July 11]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

4. British Columbia Provincial Nursing Skin and Wound Committee. Prevention of pressure injury in adults & children: guideline 2017 november. [cited 2018 July 11]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

5. National Pressure Advisory Panel, European Pressure Ulcer Advisor Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emilt Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

6. Norton L, Parslow N, Johnston D, Ho C, Afalavi A, Mark M, O’Sullivan-Drombolis D, Moffat S. Best practice recommendations for the prevention and management of pressure injuries. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 July 11]. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements

7. Sibbald, G., et al. (2011). Special considerations in wound bed preparation 2011: An update. Advances in Skin and Wound Care, 24(9), 415-436

8. Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario

9. Registered Nurses’ Association of Ontario (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition. Toronto, ON: Registered Nurses’ Association of Ontario.

10. Posthauer ME, Banks M, Dorner B, Schols JM. The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper. Advances in skin & wound care. 2015 Apr 1;28(4):175-88.

11. Orsted HL, Keast DH, Forest-Lelande L, Kuhnke JL, O’Sullivan-Drombolis D, Jin S, et al. Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Jan 23]. 73p. Available from:https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

12. British Columbia Provincial Nursing Skin and Wound Committee. Guideline: wound bed preparation for healable and non-healable wounds in adults and children. June 2015. [cited 2018 Jan 23]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

13. . Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with wound bed preparation 2015. Adv Skin Wound Care. 2015; (10):466-76

14. British Columbia Provincial Nursing Skin and Wound Committee. (2018). Guideline: Wound Management for Adults & Children. [cited 2018 Nov 7]. Available from https://www.clwk.ca/buddydrive/file/guideline-wound-management-2018-august/

15. Colwell JC. Pressure injury prevention and care. In: Clinical Nursing Skills and Techniques, 9th Edition. Perry AG, Potter PA, Ostendorf WR (Eds.). Elsevier: St. Louis, Missouri; 2018; 994.