Skin & Soft Tissue: Pressure Injury

Pressure Injury

Definition

  • Pressure Injury: Skin & Soft Tissue Injury Caused by Persistent Pressure
  • Older Terms No Longer Used: “Pressure Ulcer” or “Pressure Sore”

Staging

Stage Depth Presentation
I Epidermis Erythema but No Skin Loss
II Partial Thickness – Dermis Shallow Ulceration
III Full Thickness – Subcutaneous Exposed Adipose Tissue
VI Full Thickness – Deeper Structures Exposed Bone, Muscle or Tendon
Unstageable Unknown Base of Ulcer Covered by Slough or Eschar
Deep Tissue Pressure Injury Deep Tissue with Intact Skin Purple/Maroon Skin Discoloration or Blood-Filled Blister

Stage I 1

Stage II 1

Stage III 1

Stage IV 1

Unstageable 1

Deep Tissue Injury 1

Pathogenesis

  • Inciting Factors:
    • Pressure
    • Shearing Force
    • Friction
    • Moisture – Limited Role
  • Effects:
    • Applied Pressure Greater than Arteriolar Pressure (32 mmHg) Causes Ischemia & Reperfusion Injury
    • Direct Cell Membrane Damage
    • ECM Protein Damage
    • Reactive Oxygen Species – Increase Proinflammatory Markers & Proteolytic Enzymes
  • Most Severely Affected Tissues are Deep Near the Bone
    • Pressure Over a Bony Prominence Produces a Cone-Shaped Distribution
    • Unseen Extent of Injury is Often Greater than Superficial Ulcer May Show (“Tip of the Iceberg”)

Risk Factors

  • Immobility – Most Important Patient Factor
  • Malnutrition
  • Reduced Skin Perfusion
    • Peripheral Vascular Disease
    • Hypotension
    • Vasoconstriction & Vasopressors
  • Sensory Loss
    • Peripheral Neuropathy
    • Spinal Cord Injury
    • Dementia
    • Delirium
  • Longer Duration of Surgery
  • Depression is Associated with Recurrence

Prevention

  • Pressure Redistribution & Avoid Pressure on Bony Prominences – Most Important Preventative Measure
    • Reposition Every 2 Hours
    • Use of Support Surfaces
  • Improve Mobility – Physical & Occupational Therapies
  • Avoid Excessive Dryness or Moisture
  • Improve Nutrition
  • Improve Skin Perfusion

Treatment

  • Unstageable or Deep Tissue Pressure Injury: Debridement to Evaluate the Injury Depth
  • Stage I: Primarily Preventative Measures
  • Stage II: Local Wound Care
    • May Consider Negative-Pressure Wound Therapy (NPWT)
  • Stage III-IV: Debridement of Necrotic Tissue & Possible Flap Coverage
    • Flaps Have Lower Recurrence Rates than Primary Intention

References

  1. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016 Nov/Dec;43(6):585-597. (License: CC BY-NC-4.0)