While they may be unavoidable in some situations, pressure ulcers are the focus of many prevention strategies throughout most healthcare facilities including long-term care1. Patient symptoms and conditions, such as limited mobility and exposure to moisture, contribute significantly to the risk of skin breakdown. Furthermore, while we strive to help our patients attain their best possible health status, interventions come with risks, including the possibility of skin breakdown.
Pressure ulcers are staged based on severity, from stage 1 to 4, or are categorized as unstageable. It is imperative that you properly categorize your patient’s pressure ulcer so that interventions can be customized to your patient’s needs and healing or wound deterioration can be communicated accurately.
You must also understand that while pressure ulcers are staged 1-4, they won’t always progress in numerical order. You may discover a pressure ulcer that is already a stage 2 when you were unaware of it until now. The injury also may not heal in reverse order as expected1. Even so, staging is still a useful tool for identifying and communicating wound characteristics to the healthcare team.
A stage 2 pressure ulcer is a partial-thickness wound that exposes a layer of dermis. Unlike a stage 1 pressure ulcer, which remains closed, this stage exposes tissue that is moist and red or pink in color. Deeper tissue, such as fat, muscle or bone, is not visible at this stage. Furthermore, stage 2 pressure injuries do not contain slough (yellow/white material) or eschar (dark, dead tissue)2. If you note fat, muscle, bone, slough or eschar in the wound, you may be dealing with a stage 3, stage 4 or unstageable pressure ulcer.
While some dermatitis, skin tears, burns and abrasions will also expose a layer of dermis in much the same way as a stage 2 pressure ulcer, never document them as such. In addition to the description above, the wound must also have resulted from pressure to be considered a pressure injury2.
All patients must be evaluated for pressure ulcer risk at the time of admission, daily, and anytime the patient experiences serious skin health changes. Identifying the patient’s risk factors is an integral part of determining appropriate care plan interventions designed to prevent an occurrence of pressure injury. Depending on your organization, you may use the Braden scale or the Norton scale.
The Braden scale provides a score that correlates directly to the patient’s risk of experiencing skin breakdown. Six categories are each rated from 1-4 depending on the patient’s sensory perception, moisture assessment, activity level, mobility, nutrition and friction and shear. Each patient will receive a score between 6 and 234. Lower scores indicate higher levels of risk, while higher scores indicate lower levels of risk.
Some facilities use the Norton Scale to evaluate a patient’s risk level. Similar to the Braden scale, the Norton scale uses a grading system to screen and identify patients who are at high risk of experiencing skin breakdown. Each patient’s score is based on their physical condition, mental condition, activity and mobility levels, and continence status4. Like the Braden scale, a high score on a Norton scale is indicative of less risk, while a low score indicates higher risk.
To effectively manage your patient’s stage 2 pressure ulcer, you must first understand the risk factors that led to their condition. Age-related changes, thin or frail skin, poor mobility, poor nutrition and exposure to moisture all increase the risk of skin breakdown. Furthermore, prolonged pressure to areas of bony prominence or repeated shearing force as a result of repositioning or mobility assistance can increase skin injury risk, especially on the sacrum, heels, ears and other high-risk areas4.
If your patient has skin breakdown that you’ve identified as a stage 2 pressure ulcer, implementation of interventions must begin immediately. Start by collecting information. Your assessment should include measurements and descriptions of the wound bed as well as surrounding areas. Look for signs and symptoms of infection, including redness, warmth, discharge and odor, and carefully document your findings.
Identification of the cause of your patient’s skin breakdown is imperative, as one of your first interventions will be to prevent further damage. If a medical device is causing your patient’s pressure injury, reposition or cushion the device by placing a dressing between it and your patient’s skin. If moisture is the culprit, plan of care changes that include more frequent incontinence care may be required. Whatever the cause, identify it promptly.
Once you have thoroughly assessed your patient’s skin and pressure ulcer and identified the cause of the injury, collaborate with the patient’s care team to plan and implement strategies to prevent further injury and promote healing. Some effective strategies include:2,5-7
● Regularly assess patient risk using the facility’s chosen tool
● Identify areas of high risk and prioritize interventions accordingly
● Perform frequent skin surveillance
● Carefully measure and document wound size and shape so that healing or a deteriorating condition can be identified
● Adjust the plan of care when any changes occur
● If the wound closes, its depth increases, edges roll in, undermining or tunneling are noted, or slough or eschar become present, adjust the pressure ulcer stage accordingly
● Provide prompt attention after incontinence episodes
● Use gentle skin cleansers and moisturizers
● Before beginning treatment on a stage 2 pressure ulcer, consult with the attending physician as well as your facility’s wound team
● Cleanse the wound using sterile water or normal saline flush
● If ordered by a physician, you may apply antiseptic cream, also called triple-antibiotic ointment or TAO, to the wound bed to kill bacteria present in the wound bed. Typically, this is reserved for small wounds
● Hydrocolloid dressings can sometimes be applied to stage 2 pressure injuries. The gel-like dressings are flexible enough to be placed over bony prominences and assist by absorbing secretions and protecting the wound from bacteria and debris
● If your patient’s stage 2 pressure injury emits large amounts of discharge, an alginate dressing may be appropriate. These dressings can absorb multiple times their weight in fluid while protecting the wound from debris. Furthermore, they naturally contain sodium and calcium, minerals known to assist in wound healing
● Honey-infused dressings or honey wound gel are proven effective in assisting to heal wounds such as pressure ulcers, with antibacterial properties that assist in fending off infection
● Assess the wound for signs and symptoms of infection, including warmth, redness, odor and drainage. Document any signs and symptoms of infection and notify the attending physician immediately
● Measure and document the size and shape of any redness noted
● Assess the patient for symptoms of infection, including fever, chills, nausea, vomiting, pain, confusion and lethargy. Notify the attending physician if any symptoms are noted
● 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 and physician orders
● 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 Accora’s Configura® Advance chair, which features the BodyMove anti-shear backrest and a high-risk-compatible visco foam cushion as standard
● Consider the use of pressure-relieving devices such as the Accora 600 static foam mattress with a heel-management slope
● Utilize thin and breathable foam dressings between devices and 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
If available through your facility, the PUSH (Pressure Ulcer Scale for Healing) tool, developed by the National Pressure Ulcer Advisory Panel (NPUAP), can be used to monitor changes in your patient’s pressure ulcer status over time. Healthcare workers utilize the tool by inputting scores based on the length and width of the wound, exudate amount, and tissue type. Ratings and total scores are then tracked on a record and graph that can quickly and visually indicate if the patient's pressure injury is improving or declining8.9.
With quality care and time, a stage 2 pressure ulcer will often heal. However, patients who have experienced this type of skin breakdown should be closely monitored to ensure they don’t have a repeated episode or experience a pressure injury in another area of the body.
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. To learn more about Tammy, visit her LinkedIn page.
