Pressure Injuries.
Pressure Injuries
Let’s discuss pressure injuries, what they are, complications, and what steps we need to take as part of a nursing best practice to prevent them. First let’s briefly discuss the anatomy of skin. The skin is the largest organ in the human body and is composed of three layers, the outermost layer is called the epidermis, the middle layer is the dermis, and the inner layer is called subcutaneous tissue, following is muscle and bone. Pressure injuries have many different names such as, decubitus ulcers, pressure sores, pressure ulcers, bedsores, and pressure wounds. Pressure injuries occur during prolonged down-time which leads to decreased blood flow and oxygen delivery to tissues and ultimately causes a pressure injury.
Pressure injuries come in stages I-IV unstageable and deep tissue injury and high risk areas are bony prominences. Depending on the depth of tissue injury helps us to determine staging. A stage I pressure injury will represent a red spot that does not change color when pressed on which is called non-blanching erythema. This is the beginning of the development of a new pressure injury and in this stage there is no skin breakdown.
In a stage II pressure injury, the wound will have non-blanching erythema with partial-thickness loss to the epidermis and in some cases parts of the dermis of the skin. Stage II pressure injuries are commonly painful and the appearance can be described as abrasion or blister-like,
Stage II pressure injuries can progress into stage III pressure injuries. Stage III pressure injuries are now classified as full-thickness injuries which reach the subcutaneous layer of the skin. In this stage of pressure injury pain sensation decreases due to the severity of tissue damage.
Stage IV pressure injuries are also classified as full-thickness pressure injuries which now expose muscle, bone and/or tendon. The wound bed may have areas of yellowing which is known as slough and areas of black necrotic tissue known as eschar. This is the worst stage of pressure injuries. Blood flow is limited to the tissues which causes tunneling through all the layers of skin. Stage IV pressure injuries are painful and may lead to deadly complications which we will discuss momentarily.
Deep tissue injuries (DTI) and unstageable pressure injuries are pressure injuries that do not give us a clear idea of how much damage to tissues there is. Deep tissue injuries are dark purple and non-blanching, they are commonly painful but it is uncertain the degree of damage since the wound is closed. Unstageable pressure injuries are characterized by a layer of eschar and without removal of the dead tissue it is uncertain the degree of damage in this stage as well. Unstageable pressure injuries often can be painful, but also depending on the degree of damage, sensation may also be decreased.
The skin as we mentioned prior is the largest organ in the body. The skin is the first layer of protection from bacteria and viruses. Once the skin has an opening, it is safe to say that there is a breach within the security system of our bodies known as our immune system. The most common complication is cellulitis which is defined as “an infection of the skin and connected soft tissues”, (Mayo Clinic, n.d.). Other complications include bone and joint infections and sepsis. Severe sepsis which leads to multiorgan failure is one of the leading causes of death in the Intensive Care setting which is why prevention is so important.
Although in some instances preventing a pressure injury can seem almost impossible, as a caretaker to patients it is crucial to utilize pressure injury prevention strategies. The best way to prevent a pressure injury is mobility, but in some cases mobility is not possible. In some instances nutrition may be lacking and a diet may be adjusted to include more protein. It is important as the nurse or caregiver to recognize that each plan of care needs to be individualized. As a best practice, repositioning is the gold standard for prevention of pressure injuries in immobile patients. Offloading bony prominences, repositioning every two hours, while being mindful of other devices such as heart monitor or blood pressure cables and making sure the patient is not laying on unnecessary objects.
My background in the intensive care setting has truly taught me the importance of repositioning. Additional measures to monitor for would be body fluids. Stool and urine may also cause tissue damage due to the high acidity of the body waste. Ensuring a clean patient may not only help prevent a pressure injury from occurring, but if a patient were already compromised by an injury, a clean wound site is critical for the prevention of bacterial growth. Sadly, these prevention strategies are at times neglected and patients are the only ones who suffer. Multiorgan failure is a leading cause of death in the intensive care setting and having an infected wound can lead the way to developing sepsis which is an infection that has spread into the bloodstream and if untreated will lead to multiorgan failure. As nurses or caregivers we owe it to our patients to prevent pressure injuries. Let’s be proactive and protect our patients from preventable complications.
Reference
Mayo Foundation for Medical Education and Research. (2023, May 13). Bedsores (pressure ulcers). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-causes/syc-20355893
