Chapter 4: Pressure Injury/Ulcers

INTRODUCTION

Pressure injury/ulcers (PI/PUs) are a result of prolonged direct pressure, shear, or friction forces that injure soft tissue between the skin and underlying bony prominences. The sacrum/coccyx, heels, and greater trochanters are the anatomical areas most vulnerable to tissue injury; however, PUs can also occur on the occiput, ear, spine, scapula, acromion process, elbow, medial and lateral femoral condyles, patella, malleoli, and metatarsals—anywhere that there is little or no soft tissue over the bony prominence to dissipate the external and internal mechanical forces. The area most at risk depends upon the individual’s body build. Therefore, any treatment plan for prevention and/or treatment has to be very patient-specific. The global strategies for prevention are repositioning, mobilization, frequent skin assessments, skin protection, moisture management, adequate nutrition, and avoidance of shear and friction during functional activities. And of paramount importance is finding the source of the mechanical pressure, which is not always what it appears to be initially. For example, a PU on the lateral hip may appear to be from lying on one side too long; however, it could also occur from sitting in a wheelchair that is too narrow.¹ The root-cause analysis of a PU, especially a deeper one, is determined by what the patient was doing, the surface upon which the patient was sitting/lying, and other risk factors, 48 hours prior to admission to a facility.²

Moisture per se is no longer considered a cause of pressure injury; however, exposure to urinary or fecal incontinence, wound drainage, or perspiration causes the skin to break down, therefore making it easier for bacteria to penetrate the skin. Moisture also changes the pH of the skin. Both of these consequences can increase the risk for a PU to develop and affect the healing potential. Other conditions that can affect the ability of the tissue to withstand pressure and shear are the microclimate, nutrition, perfusion, co-morbidities (e.g. diabetes, cardiac disease), and condition of the soft tissue (e.g. presence of scarring from previous wound healing, emaciation). All of these factors are to be considered when evaluating a patient with a PU, in addition to performing a vascular assessment of any lower extremity that may have compromised healing due to arterial insufficiency.

Treatment of the wound itself includes debridement of necrotic tissue and bio-film (either sharp, surgical, or enzymatic depending on the amount of tissue to be removed and the patient medical status), treatment of any infection, moist wound healing, and adjunct therapies when appropriate (e.g. electrical stimulation, pulsed lavage with suction, ultraviolet C, negative pressure wound therapy).

The National Pressure Injury Advisory Panel (NPIAP) has developed six classifications of PUs based on the depth of tissue damage,³ and although the Panel uses the term pressure injury,⁴ Center for Medicare & Medicaid Services (CMS) still refers to them as PUs in the ICD-10 coding.^* NPIAP also describes other skin disorders frequently documented as ...