Continuing Education Activity

Pressure injuries are formed when pressure causes localized damage to underlying skin and soft tissue. These skin and soft tissue injuries remain a significant problem within hospitals and long-term care facilities and result in decreased quality of life and high costs for both the patient and our health care system. To avoid the high morbidity and mortality associated with these pressure injuries, they must be promptly diagnosed and treated. This activity reviews the evaluation and management of pressure injuries and highlights the role of the interprofessional team in improving care for patients with pressure injuries.

Objectives:

• Identify the etiology of pressure injuries.
• Outline the appropriate evaluation of pressure injuries.
• Review the management options available for pressure injuries.
• Describe interprofessional team strategies for improving care coordination and communication to advance the treatment of pressure injuries and improve outcomes.

Introduction

Pressure injuries are defined as localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices. They are the result of prolonged or severe pressure with contributions from shear and friction forces. These skin and soft tissue injuries remain a significant problem within hospitals and long-term care facilities and result in decreased quality of life, high costs for both the patient and our health care system, as well as increased morbidity and mortality.[1] As pressure injuries may be considered an indicator of the quality of care of a facility, inadequate steps in prevention or treatment can lead to litigation.[2] Awareness of factors that may contribute to the pathogenesis of pressure injuries enables the identification of those patients at risk for their development, and preventive measures can be aimed towards these particular patients. As treatments for pressure injuries have been characterized and evaluated with variable degrees of completeness, there remains uncertainty regarding the best options for management.[3]

Etiology

The pressure of an individual’s body weight or pressure from a medical device above a certain threshold for a prolonged period is thought to be the cause of pressure injuries. In patients with sensory deficits, an absent pressure feedback response may result in sustained pressure for a prolonged period, leading to tissue injury. Many factors are identified in contributing to pressure ulcer and injury formation, such as increased arteriole pressure, shearing forces, friction, moisture, and nutrition status.[1]

Epidemiology

Pressure injuries of the skin and soft tissues affect an estimated 1 to 3 million people in the United States each year. The incidence differs based on the clinical setting. For example, the prevalence of pressure injuries among hospitalized patients is 5% to 15%, with the percentage considerably higher in some long-term care environments and intensive care units.[1] Risk factors for developing pressure injuries, in general, include immobility, reduced perfusion, malnutrition, and sensory loss.[4][5][6] Other patients at increased risk for pressure injury development include those with cerebrovascular or cardiovascular disease, recent fracture of a lower extremity, diabetes, and incontinence.[7][8][2] Older patients are also at increased risk for the formation of pressure injuries due to skin changes associated with aging, including thinning of the dermis and epidermis, resulting in decreased resistance to shear forces.

Pathophysiology

Pressure injuries of the skin and soft tissue are formed when the pressure above a certain threshold causes prolonged tissue ischemia, eventually leading to necrosis. Injury from reperfusion is also a contributing factor, as the return of blood supply after a period of ischemia can cause the formation of reactive oxygen species triggering an inflammatory response. In patients positioned at an incline, internal structures such as bone and muscle are displaced downward due to gravity, which can lead to tissue hypoxia as blood vessels are distorted or flattened.[1]

One type of pressure injury is the Kennedy ulcer. It occurs suddenly in a terminal patient. There are gaps regarding the physiopathology of this ulcer as the current knowledge is based on hypotheses. There is a lack of knowledge about care approaches, but, it is clear that the main objective in this situation at the end of life would be to prioritize patient comfort and quality of life.

History and Physical

Obtaining specific information from a patient’s history can help determine any potential risk factors for wound development and nonhealing. Providers should ask regarding a patient’s prior history of wounds along with their etiology, location, duration, and treatment. Inquiring specifically about medical conditions such as diabetes and associated neuropathy, chronic kidney disease, peripheral artery disease, immunocompromised states, impaired nutritional status may give providers more information about a patient’s healing potential.[9][10]Patients may be able to provide qualitative information regarding their current wound history, including:

• location
• duration
• potential causes or inciting factors
• changes in size
• pain (type, severity, frequency, aggravating or alleviating factors)
• previous wound manipulation or treatment
• presence of erythema, odor, or exudate

It can be important to assess certain locations for any signs of pressure injury during one’s physical exam. Pressure injuries commonly develop in these areas[1]:

• sacrum
• greater trochanter
• ischial tuberosity
• lateral malleolus
• the heel of the foot

Characteristics of pressure injuries that should be assessed include but are not limited to:

• location
• length
• width
• depth (both quantitative and qualitative)

 It can also be important to document the presence of any of the following:

• undermining
• tunneling
• necrosis
• signs of infection
  • erythema
  • induration
  • warmth
  • tenderness or pain with palpation
  • drainage (also noting amount, type, odor, color)

Evaluation

A staging system should be used to assess all pressure injuries. At this time, there is a lack of a universal classification system for pressure injuries, but the National Pressure Injury Advisory Panel staging system is widely used as listed below [1][2]:

• stage 1: non-blanchable erythema of intact skin and erythema remains for greater than one hour after relief of pressure
• stage 2: partial-thickness loss of skin with exposed dermis
• stage 3: full-thickness loss of skin tissue; subcutaneous skin and muscle may be visible
• stage 4: full-thickness loss of skin tissue; tendons, bone, and joints may be visible
• unstageable: full-thickness loss of skin tissue that is obscured by eschar or slough
• deep tissue: skin that is persistently non-blanchable, with maroon or purple discoloration

The laboratory studies listed below can be obtained to assess for conditions that can lead to the formation of non-healing injuries, such as infection, anemia, poor nutritional status, and diabetes[11]:

• comprehensive metabolic panel
• complete blood count with differential
• albumin and pre-albumin (to assess nutrition status)
• hemoglobin A1c

Wound cultures from superficial swabs may not be clinically useful as they usually reflect colonization rather than infection. Cultures from bone or deep tissue should not be used as a sole indicator of infection; they should be interpreted in the context of the clinical setting and other histopathological data.[12]

Treatment / Management

General Care

General care for pressure injuries can include redistribution of pressure with the use of support surfaces and changes in positioning. Redistribution of pressure and appropriate patient positioning is required to prevent the development and worsening of pressure injuries, as these methods can reduce force from friction and shear. In patients with a high risk of developing pressure injuries, support surfaces to alleviate pressure can be used. This can include higher-speciation foam mattresses, medical-grade sheepskins, continuous low-pressure supports, alternating-pressure devices, low air loss therapy; however, the effectiveness of these devices compared to other surfaces in the treatment of existing pressure injuries has not been conclusively established.[13][14] Based on ACP clinical practice guidelines from 2015, providers should select advanced static mattresses or mattress overlays consisting of foam, sheepskin, or gel in patients at increased susceptibility to the formation of pressure injuries. The guidelines also advise against the use of alternating-air mattresses or overlays in this patient population; however, only moderate quality evidence has been utilized to support these two recommendations.[15] Although there is not adequate evidence to assess the effectiveness of repositioning patients on the healing rates of pressure injuries, it remains a practice with good face value to maintain patient positioning, which minimizes wound pressure.[16]Part of treatment for pressure injuries also includes pain control and optimization of nutrition. Pain frequently occurs at dressing related procedures. Pain control can be achieved with individualized analgesic regimens as well as skilled wound management.[17] It is important to optimize total caloric intake and protein intake in patients with pressure injuries, especially for patients with stage 3 and 4 pressure injuries.[18] ACP clinical guidelines from 2015 recommend the use of supplementation with protein or amino acids to reduce wound size in patients with pressure injuries; however, the evidence to support this recommendation is low quality.[19]

Wound Management

Wound care, including maintaining a clean environment, debridement, application of dressings, monitoring, and various adjunctive therapies, is generally advised to facilitate the healing of pressure injuries. Options for treatment can be guided by the stage of the pressure injury. Stage 1 pressure injuries can be covered with transparent film dressings as needed. Stage 2 pressure injuries benefit from a moist wound environment. Occlusive dressings (foam, hydrogels, and hydrocolloids) and non-occlusive dressings (transparent films) can be used to achieve this. Treatment of stage 3 and 4 injuries is based on the presence of necrotic tissue. Pressure injury treatment also involves preventing contamination of the wound as well as maintaining a clean wound environment.[19] Wounds with necrotic tissue or eschar require debridement, whether by sharp, mechanical, autolytic, or bio surgical method, to expose granulation tissue, facilitate healing and reduce the risk of infection prior to placement of moist to absorbent dressing.[11]Dressings and topical agents are commonly used to treat pressure injuries, but it is unclear whether one dressing or topical agent is superior to another. Appropriate selection of dressings may be based on wound characteristics, cost, or patient preference and includes hydrocolloids, hydrogels, transparent films, foams, and alginates.[20][11] ACP clinical practice guidelines from 2015 recommend the use of foam or hydrocolloid dressings to reduce the size of pressure injuries.[19] Additional therapies such as negative-pressure wound therapy, electromagnetic therapy, phototherapy, therapeutic ultrasound, and reconstructive surgery are used to treat pressure injuries, but there is limited data regarding their efficacy in wound healing.[21][22][23][24][25] Based on moderate-quality evidence, ACP clinical practice guidelines from 2015 recommend the use of electrical stimulation as a supplemental therapy to accelerate wound healing in patients with pressure injuries.[19] In addition to the above treatments, monitoring to assess the healing of pressure injuries should be implemented, which can be done with the utilization of healing scales. The two most common instruments for this include the Pressure Ulcer Scale for Healing and the Pressure Sore Status Tool.[2]

Differential Diagnosis

The differential diagnosis for pressure injuries is important to consider to appropriately treat this condition. This differential can include but is not limited to [26]:

• Venous insufficiency ulcers
• Diabetic neuropathic ulcers
• Arterial/ischemic ulcers
• Ulcers associated with malignancy
• Hypertensive ulcers

Prognosis

The presence of a pressure injury can be indicative of a poor overall prognosis for a patient.[27] An increased risk of death in both elderly and intensive care patients has been associated with the presence of pressure injuries; however, pressure injuries may be a sign of the underlying severity of disease instead of an independent predictor of mortality.[28] Additional clinical conditions that remain unmeasured may be contributing to the increased morbidity and mortality associated with pressure injuries.[29]

Complications

Infection is a significant complication of pressure injuries, and the manifestations can be widely variable. This can include local wound infection as well as soft tissue infection, osteomyelitis, and bacteremia. Osteomyelitis can manifest as a wound with delayed healing and does not always include systemic signs such as sepsis or leukocytosis. Bacteremia is usually more apparent as it is typically accompanied by signs of a systemic inflammatory response. Evaluation of pressure injuries for infection can require a combination of clinical assessment and judgment, microbiological and histopathological evaluation, and imaging studies. The goals of infection control include preventing the spread of pathogens to other patients, staff, and the surrounding environment and avoiding the selection of resistant microorganisms.[12]

Deterrence and Patient Education

Deterrence of pressure injuries includes identification of patients at risk, improvement of overall health, reducing external forces, and promoting education about pressure injuries. American College of Physicians (ACP) clinical practice guidelines from 2015 advise performing a risk assessment to recognize patients at risk of pressure injury formation.[15] Several scales have been created to predict the risk of pressure injuries in order to identify patients for whom prevention measures or early treatment should be considered. The most commonly used tools for this are the Braden and Norton scales. Reducing external forces includes minimizing extrinsic risk factors, such as friction, shear, pressure, and moisture, which is important for the deterrence of pressure injury formation. Evidence has demonstrated that the education of both providers and patients can lead to a decrease in the incidence of pressure injuries as well as an increase in the ability to manage them.[12][30]

Enhancing Healthcare Team Outcomes

When pressure injuries develop, systems should be able to identify issues leading to their occurrence and implement methods for resolving these issues. There is increasing evidence that multidisciplinary interventions aimed to prevent pressure injuries in both long-term care facilities and acute care settings can have success in decreasing the prevalence or incidence rates of pressure injuries. This can include clinical staff becoming more involved at the patient care level, bundling of care practices, and incorporating them into routine care, making documentation of pressure injury prevention practices more visible, and educating all staff on a regular basis. In terms of implementing these interventions, the more often new care practices are merged with usual care practices, the more likely staff will be to perform them on a consistent basis with better outcomes overall.[31]