Written by Janis Harrison, RN, BSN, CWOCN, FCFN
The guideline to pressure injuries that I like to follow is well defined by the National Pressure Ulcer Advisory Panel (NPUAP).
Let's start by defining what a pressure injury is -
A pressure injury is localized damage to the skin and/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. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (NPUAP)
This means we need to inspect areas such as the heels, sacrum, elbows, scapula, back of the head, knees, hips, and any other prominent bony or soft tissue (back of ears) for discoloration, redness, breaks in the skin while being aware of localized pain.
Who is at risk for pressure injury formation?
• Elderly individuals with other co-morbidities such as fluid abnormalities, diabetes, dementia, and change in living quarter, and nutritional compromise.
• Patients with a spinal cord injury are at risk due to the inability to move.
• Patients who are in surgery for long periods of time (4 hours or more) are at risk due to the way they are positioned or the lack of repositioning.
• Obese patients, due to the inability to move or turn themselves
• Underweight patients as there is no padding over the boney prominences.
Staging Pressure Injuries
Stage 1 Pressure Injury
Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darly pigmented skin. Presence of blanchable erythema or changes in sensation, tenderness, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. (NPUAP)
The need to move or turn the patient when finding a non-blanchable erythema area is imperative. We want to get the patient off of the area of pressure to decrease the change of progression to the next stage. Never massage the area of redness as this will only cause more tissue damage.
No dressings are necessary for this stage as there is no break in the skin. However, studies have shown that patients unable to move and are undergoing long surgeries have had sacral dressing with silicone borders attached to the sacrum and incidence of breakdown has declined. This practice has also decreased injuries related to friction and shear.
Stage 2 Pressure Injury
Partial-thickness skin loss with exposed dermis
The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.
This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). (NPUAP)
Finding a break in the epidermis and to the dermis is easily managed with a foam island or a gauze island dressing. But again, it is necessary to remove the pressure and redistribute the weight from the boney prominence.
Your facility may have a pressure ulcer prevention and management program in place. Using the Braden scale or a Pressure Prevention Tool to see who is at risk is helpful. Addressing any co-morbidities and personal individual needs should be policy.
Some helpful dressings for prevention of pressure for the immobile patient include Mepilex border, Allevyn Life, KerraFoam with border; just to name a few. Your Halo team can help you with your dressing needs.
IMPORTANT NOTE FROM THE HALO TEAM: While the dressings mentioned above are stocked by Halo, they each come with their own set of criteria for coverage. Medicare's Surgical Dressing policy provides coverage for surgical/wound dressings when a qualified wound is present. Furthermore, the Local Coverage Determination implies the following coverage guidelines:
Foam Dressing Or Wound Filler (A6209-A6215)
Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate. Dressing change for a foam wound cover used as a primary dressing is up to 3 times per week. When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change is up to 3 times per week.
Please click here to view Local Coverage Determination Article #L33831 and contact your Halo team with any questions.
Halo Service Team (888)711-2014
Meet the Author
Janis Harrison, RN, BSN, C.W.O.C.N & C.F.C.N. is the owner of Harrison WOC Services, L.L.C. in Thurston, Nebraska. A graduate of Morningside College, Janis works as an independent contractor of Wound, Ostomy, Continence, and Foot and Nail Care services for medical entities throughout Northeast Nebraska. With over 30 years of experience as a nurse and 12 years as a CWOCN and CFCN, she found her passion for wound care when her spouse was afflicted with many complications from four consecutively failed surgeries that involved his ostomy. Through this experience, it became obvious that rural Northeast Nebraska was in need of wound and ostomy nursing care. After her husband survived an nine additional surgeries, Janis enrolled and graduated from the WOC Nursing program. Along with writing case studies, poster abstracts, newsletters, consulting with KCI and in-services, Janis has also helped to write and is the Chief Clinical Consultant of WoundRight, which is a documentation app available for tablets.