Ask any healthcare worker what they worry about most, and pressure injury, also known as pressure ulcers, decubitus ulcers or bedsores, will be one of their top three concerns, along with hospital-acquired infections and falls. Sometimes unavoidable1, the injury to the skin that results from sustained or repeated pressure to a high-risk area leads to poor health outcomes for the patient and substantial treatment costs for the organization. Fortunately, actionable, evidence-based interventions can be implemented to prevent skin breakdown or provide healing care when it occurs. Let’s review the best strategies for pressure ulcer identification, prevention and management in the first article of this three-part series.
Pressure ulcers are categorized into four stages depending on their severity. However, this does not mean that each patient’s injury will progress through the stages in order or that they will heal in reverse order1. Staging is an excellent tool for identifying and documenting a wound’s characteristics and can assist the healthcare team in determining the best plan of care.
A stage 1 pressure ulcer involves non-blanchable erythema (redness) of intact skin. During this stage, the patient may experience a change in sensation to the area, or the area may feel warm or firm2. A thorough assessment may reveal that the area was red but blanchable beforehand, alerting the healthcare team that a pressure injury may result if the cause of pressure is not mitigated.
In patients with darker skin tones, the color change is sometimes difficult to identify. In this case, look for any visual change in the skin in addition to redness or firmness of the area.
A stage 2 pressure ulcer is a partial-thickness wound that exposes a layer of dermis. The exposed tissue will be moist and red or pink in color. Deeper tissue such as fat, muscle or bone are not visible at this stage2.
Stage 3 pressure ulcers involve full-thickness skin loss. Fat tissue is visible at this stage. The wound edges may roll under, and you may notice undermining or tunneling. Slough (yellow/white material) or eschar (dark, dead tissue) may be present as well. Muscles, tendons and bones are not visible at this stage2.
With full-thickness skin and tissue loss, a stage 4 pressure ulcer is the most severe stage. These wounds will present with palpable muscle, tendons, ligaments, and bones. Slough (yellow/white material) and eschar (dark, dead tissue) may also be present. You may also identify rolled edges, tunneling, or undermining in the wound2.
Some pressure injuries cannot be staged accurately due to the presence of slough or eschar that obscures your view of the wound bed2. These pressure ulcers must be documented as unstageable until the wound bed can be assessed more thoroughly. Do not remove the slough or eschar in an effort to stage the wound.
While not a stage in and of itself, the Kennedy ulcer can easily be mistaken for a pressure injury resulting from poor care. However, this ulcer often appears quickly, within just a few hours, due to decreased blood flow to the skin as part of the dying process3. If your patient is terminally ill and suddenly develops a butterfly or irregularly shaped open area that presents like a pressure wound, they likely have a Kennedy ulcer. Treatment for these wounds is usually palliative in nature.
When it comes to pressure ulcers, an ounce of prevention really is worth a pound of cure. The best prevention begins with risk assessment. When your patient is initially admitted or upon first contact, perform a thorough skin assessment and utilize your organization’s preferred scale to determine your patient’s risk level. Document and communicate any noted skin concerns, then utilize the patient’s risk level to formulate a plan of care, including pressure ulcer prevention strategies.
The Braden and Norton scales are the most commonly used evaluations for determining the risk of skin breakdown in patients.
The Braden scale is a tool that rates a patient’s risk of skin breakdown according to six categories. Each category is assigned a score, with lower scores indicating higher risk levels and higher scores indicating lower risk4.
Sensory Perception-The ability to respond to discomfort
(1 point) Completely limited
(2 points) Very limited
(3 points) Slightly limited
(4 points) No impairment
Moisture-Frequency and degree of exposure to moisture
(1 point) Constantly moist
(2 points) Very moist
(3 points) Occasionally moist
(4 points) Rarely moist
Activity-Physical activity level
(1 point) Bedfast
(2 points) Chairfast
(3 points) Walks occasionally
(4 points) Walks frequently
Mobility-Ability to change body position
(1 point) Completely immobile
(2 points) Very limited
(3 points) Slightly limited
(4 points) No limitation
Nutrition-Food intake levels
(1 point) Very poor
(2 points) Probably inadequate
(3 points) Adequate
(4 points) Excellent
Friction & Shear-Probability of occurrence
(1 point) Problem
(2 points) Potential problem
(3 points) No apparent problem
If your organization doesn’t utilize the Braden scale, they likely use the Norton scale to determine pressure injury risk in their patients. Like the Braden scale, the Norton scale is simple to use and provides an immediate score that can be used to determine a patient’s risk of experiencing a pressure injury. Much like the Braden score, a Norton scale score indicates high risk when the score is low and low risk when the score is high4. The five Norton scoring categories are listed below.
Physical Condition-Overall physical health
(1 point) Very bad
(2 points) Poor
(3 points) Fair
(4 points) Good
Mental Condition-Current mental status
(1 point) Stuporous
(2 points) Confused
(3 points) Apathetic
(4 points) Alert
Activity-Activity status
(1 point) Bedfast
(2 points) Chairbound
(3 points) Walks with help
(4 points) Ambulant
Mobility-Mobility status
(1 point) Immobile
(2 points) Very limited
(3 points) Slightly impaired
(4 points) Full
Incontinence-Type and frequency
(1 point) Urinary and fecal
(2 points) Usually urinary
(3 points) Occasional
(4 points) None
Effective management of pressure ulcers starts with understanding and managing the risk factors that cause them. Many of the contributing factors are related to normal aging, while some result from acute illness or poor overall health. Furthermore, healthcare professionals working in long-term care settings deal with specific challenges related to their often elderly and chronically ill population. Many of these residents are high-risk for multiple reasons, and facilities sometimes struggle to provide adequate staffing to perform routine skin checks and preventative measures. In spite of the challenges, the healthcare team must work to remain diligent in their assessments, surveillance and management of the patient’s skin.
Prolonged or repeated pressure or shearing force to areas of bony prominence leads to pressure injury. The most common pressure injury sites are4:
● Sacrum
● Heels
● Greater trochanter
● Ischial tuberosity
● Back of the head
● Ears
● Shoulders
● Elbows
● Inner knees
● Ankle
Risk factors that contribute heavily to the skin’s breakdown and require added management include4:
● Thin or fragile skin
● Decreased blood flow
● Low muscle mass
● Poor mobility
● Poor nutritional status
● Moisture due to incontinence
If you’ve identified a stage 1 pressure ulcer on your patient, interventions must be put in place immediately. If left untreated, the injury can worsen quickly, becoming more challenging to manage.
Start by analyzing the cause of the pressure injury. Was the patient lying in the same position in their bed for extended periods of time? Is an oxygen tube or other medical device pressed against the patient’s skin? Has the patient’s skin been exposed to moisture for extended periods? Does the healthcare team have a difficult time repositioning the patient, causing them to slide them against their bedding repeatedly? Is the patient’s nutritional status poor? If the cause of the pressure ulcer isn’t clear, it may be helpful to perform an assessment via the Braden or Norton Scale to help identify factors leading to the patient's injury.
Once you’ve identified the causative factors associated with the pressure ulcer, you can generate care plan interventions to prevent worsening skin breakdown and additional injuries. Some primary strategies include2,5:
● Frequently assess patient risk using the facility’s chosen tool
● Identify areas of high risk and prioritize interventions accordingly
● Perform frequent skin surveillance
● Adjust the plan of care when any changes occur
● Provide prompt attention after incontinence episodes
● Use gentle skin cleansers and moisturizers
● Apply medicated creams/powders as ordered by the physician
● Assess the patient’s nutritional status
● Implement weight monitoring
● Assist the patient with meals if necessary
● Create and implement a nutritional plan with the assistance of a dietitian
● Provide dietary supplements according to a dietitian's recommendations
● Avoid positioning the patient on the pressure area
● Follow turn and reposition protocols for your facility
● Increase turn and reposition frequency when the patient is in a chair
● Consider the use of pressure-relieving devices such as the Accora 600 static foam mattress with a heel management slope
● Swap out standard chairs with Accora’s Configura Advance tilt-in-space chair with integrated pressure-relieving cushion and anti-shear backrest
● Utilize thin or breathable foam dressings between devices and the patient’s skin when possible
● Utilize heel offloading devices when possible
● Educate the patient and family on the risks and management of pressure injuries
● Assist patient and family in implementing risk reduction and management strategies
While some pressure injuries are unavoidable, most can be prevented or managed with easily implemented patient care strategies. If you discover that your patient is experiencing skin breakdown, start by consulting a certified wound care specialist or wound care nurse. Next, thoroughly communicate their recommendations to the entire healthcare team. Then, prioritize the steps to identifying and managing a stage 1 pressure ulcer: perform regular risk assessments, monitor the patient’s skin for changes, treat skin breakdown according to physician orders, and implement preventative measures to avoid further injury. Doing so will ensure success in preventing additional injuries and providing safe patient care.
1. https://cdn.ymaws.com/npiap.com/resource/resmgr/npuap-position-statement-on-.pdf
2. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/preventing-pressure-injuries/
3. https://www.nursinghomelawcenter.org/bed-sores-in-nursing-home/what-is-a-kennedy-terminal-ulcer/#:~:text=The%20Kennedy%20ulcers%20may%20develop,necrotic%20wound%20as%20it%20worsens.
4. https://www.ncbi.nlm.nih.gov/books/NBK532897/#:~:text=Stage%201%3A%20just%20erythema%20of,of%20the%20muscle%20or%20bone
5. https://npiap.com/page/PreventionPoints
Tammy McKinney, RN, is a seasoned registered nurse and skilled healthcare writer. Specializing in patient and caregiver education, she leverages her diverse experience in acute care, long-term care, and hospice & palliative care to simplify complex medical concepts and deliver informative and engaging content.
