Pressure injury prevention and management

The following information about pressure injury prevention and management is taken from 3D Regional HealthPathways, accessed June 2020:

Background

About pressure injury prevention and management

A pressure injury is localised damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device.

The injury can present as intact skin or an open ulcer and may be painful.

Pressure injury to the skin or underlying tissue can be caused by:

• pressure through compression of soft tissue between a bony prominence and a hard surface, resulting in cellular damage, inflammation, and ischaemia.
• shear through tangential load causing the outer skin layers to remain stationary while the deep fascia moves with the skeleton. This distorts blood vessels and lymphatics, resulting in capillary occlusion and thrombosis.

The tolerance of soft tissue for pressure and shear may also be affected by:

• microclimate – increased humidity and temperature (e.g., due to sweat, incontinence) between the skin and supporting surface reduces the skin's ability to protect against pressure and shear forces.
• nutrition.
• perfusion.
• co-morbidities.
• condition of the soft tissue.

Assessment

1. Regularly screen for risk of pressure injuries in all patients with risk factors. Use the Braden scale pressure injury risk prediction tool to score the patient's risk:
     • Low risk: ≥ 19
     • Moderate risk: 13 to 18
     • High risk: ≤ 12
2. If the patient is at moderate or high risk of pressure injury, or if a pressure injury has been identified, assess:
     • the skin for pressure injuries – pay particular attention to vulnerable areas e.g., bony areas (especially the sacrum and heels) and under or around medical devices.
     • support surfaces – for support and positioning.
     • mobility.
     • incontinence or other moisture e.g., perspiration, wound exudate.
     • nutrition.
3. If pressure injury is identified, also:
     • take a history of the injury.
     • consider the underlying cause of the injury.
     • consider other factors that may affect healing.
     • stage the pressure injury.
     • determine the goal of wound care (e.g., wound healing, wound maintenance, or non-healing) with the patient, family, and healthcare team.

Management

1. If critical limb ischaemia (rest pain and/or tissue loss with absent pulses), request acute vascular surgery assessment.
2. Request acute plastic surgery assessment if pressure injury with:
     • sepsis.
     • deep cavity.
     •bone, muscle, or tendon visible.
3. If acute specialist assessment is not required and the patient has a pressure injury or is at risk of a pressure injury:
     • implement the SSKIN bundle:
           ◊ Skin – Ensure regular reassessments.
           ◊ Surface – Ensure supportive surface and appropriate positioning at all times.
           ◊ Keep moving – Ensure regular repositioning.
           ◊ Incontinence or other moisture – Keep dry and clean.
           ◊ Nutrition – Encourage healthy diet and regular fluid intake.
     • treat any other factors that may affect wound healing:
           ◊ Co-morbidities e.g., improve heart failure, optimise diabetes control, reduce risk factors for peripheral vascular disease.
           ◊ Reduce or stop medications that may affect healing, if possible.
           ◊ Advise smoking cessation – if surgical intervention is being considered, patients who smoke will not be accepted.
           ◊ Advise adequate rest and sleep.
4. Follow general wound care advice to manage any pressure injuries and surrounding skin.
5. Consider pain relief for dressing procedures and when changing position. See Analgesia in Adults with Acute Pain.
6. Lodge an ACC claim if general injury, or if treatment injury is suspected.
7. Arrange regular review at appropriate clinical intervals e.g., weekly.
8. If pressure areas are not improving, request specialised wound care nursing or seek plastic surgery advice.
9. Reassess risk:
     • if an event reduces the patient's mobility or ability to maintain skin integrity.
     • at appropriate intervals dependent on risk e.g., every 3 to 6 months.
     • on transfer from hospital or other facility.

Learn more

Guiding principles for pressure injury prevention and management in New Zealand ACC, NZ
Prevention and treatment of pressure ulcers: quick reference guide National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance
How to classify and document pressure injuries New Zealand Wound Care Society

References

1. Pressure injury prevention and management 3D Regional HealthPathways, NZ, 2020