Understanding Pressure Injuries and Prevention
What Are Pressure Injuries?
Pressure injuries (formerly called pressure ulcers) are localized areas of tissue damage from sustained pressure on skin and underlying tissues. These are most common in immobile patients and remain a major healthcare quality indicator.
The NPUAP staging system classifies pressure injuries into four stages plus two additional categories:
- Stage 1: Non-blanching erythema on intact skin. The area appears red but does not turn white when pressed.
- Stage 2: Partial-thickness skin loss. You see a shallow open ulcer or intact blister.
- Stage 3: Full-thickness skin loss exposing subcutaneous tissue beneath.
- Stage 4: Full-thickness tissue loss with exposed muscle, bone, or tendon.
- Suspected Deep Tissue Injury (SDTI): Purple or maroon discolored intact skin or blood-filled blister.
- Unstageable: Full-thickness skin and tissue loss with base covered by slough or eschar.
Prevention Strategies
Nursing prevention focuses on relieving sustained pressure before injury develops. Key interventions include:
- Reposition every 2 hours
- Use pressure-relieving devices (foam mattresses, air beds, gel overlays)
- Maintain skin hygiene and moisture balance
- Ensure adequate nutrition and hydration
- Provide patient education on mobility
- Assess risk using the Braden Scale
The Braden Scale identifies vulnerable patients early, allowing preventive interventions before tissue damage begins.
Wound Assessment and Classification
Key Assessment Parameters
Comprehensive wound assessment determines treatment and predicts healing outcomes. Evaluate these dimensions:
- Size (length, width, depth in centimeters)
- Location on the body
- Wound bed composition (percentage of granulation tissue, slough, eschar, necrotic tissue)
- Exudate characteristics (amount, color, consistency, odor)
- Surrounding skin condition
- Signs of infection
- Pain level
Wound Classification by Depth
Wounds are classified based on tissue involvement:
- Superficial: Epidermis only
- Partial-thickness: Through epidermis into dermis, but dermis preserved
- Full-thickness: Penetrates completely through dermis into subcutaneous tissue or deeper structures
Understanding Wound Bed Colors
The color of wound tissue indicates healing stage:
- Red tissue: Healthy granulation tissue and active healing
- Yellow tissue: Slough or fibrin deposits requiring removal
- Black tissue: Necrotic tissue needing debridement
Healing Phase Assessment
Determine which healing phase the wound is in:
- Inflammatory phase: Days 0-3 (normal redness, warmth, exudate)
- Proliferative phase: Days 3-21 (granulation tissue forms)
- Remodeling phase: Days 21 to 2 years (collagen strengthens scar)
Document with objective measurements and consistent photographs for tracking progress.
Wound Care Protocols and Dressing Selection
The Moist Wound Healing Principle
Moist wound healing supports faster epithelialization compared to air-drying. When wounds air-dry, scabs form and actually impede cell migration. Moist conditions accelerate healing by 20-50% by supporting cell migration, angiogenesis, and collagen deposition.
Proper Wound Cleansing
Gently cleanse wounds to remove debris and bacteria without disrupting new tissue. Use normal saline as the standard irrigation solution. Avoid hydrogen peroxide and iodine solutions, which are cytotoxic to healing tissues.
Dressing Selection Guide
Choose dressings based on wound characteristics and healing stage:
- Transparent films: Moisture retention and visualization for superficial wounds
- Hydrogels: Maintain moisture for dry or necrotic wounds
- Alginates: Absorb moderate to heavy exudate
- Foams: Manage moderate exudate with cushioning and insulation
- Antimicrobial dressings: Silver, iodine, or honey for infected or high-risk wounds
Advanced Therapies
Negative pressure wound therapy (NPWT) uses controlled suction to promote healing in complex wounds by removing fluid, reducing bacterial load, and stimulating granulation tissue. Enzymatic debridement agents like collagenase break down necrotic tissue selectively without harming viable cells.
Change dressings typically daily to every three days based on the specific product. Follow aseptic technique and assess progress at each change.
Factors Affecting Wound Healing and Complications
Intrinsic and Extrinsic Factors
Multiple factors influence healing rate and quality. Address these during assessment:
- Nutrition: Protein for collagen synthesis, vitamins A, C, E for cellular repair, zinc and iron for immune function
- Hydration: Dehydration impairs cellular function and oxygen transport
- Age: Older adults heal more slowly due to decreased collagen production and slower inflammation
- Chronic conditions: Diabetes impairs immune function and microvascular perfusion
- Immunosuppression: Medications or disease states compromise healing phases
- Hypoxia: Poor circulation, anemia, or respiratory disease significantly impair healing since oxygen is essential for collagen synthesis
- Infection: Prolongs inflammation and can lead to sepsis
- Psychological stress: Can suppress immune function and slow healing
Common Wound Complications
Recognize and prevent these serious complications:
- Dehiscence: Separation of wound edges
- Evisceration: Protrusion of internal organs
- Fistula formation: Abnormal passageways between structures
- Excessive scarring or keloid formation: Overgrowth of scar tissue
Pain Management
Manage pain during wound care and healing. Pain impairs compliance and suppresses immune function, so addressing discomfort is clinically important.
Special Wound Types and Specialized Care
Surgical Wounds
Surgical wounds heal by primary intention with clean edges approximated by sutures or staples. They progress through predictable healing phases with minimal infection risk if properly managed.
Traumatic Wounds
Wounds from accidents or injuries may involve contamination and deep structure damage. Assess thoroughly, cleanse aggressively, and evaluate tetanus status.
Chronic Wounds
Different chronic wounds require specialized approaches:
- Diabetic foot ulcers: Result from neuropathy and ischemia, requiring aggressive offloading and vascular assessment
- Venous stasis ulcers: From chronic venous insufficiency, requiring compression therapy and leg elevation
- Arterial ulcers: From peripheral arterial disease, appearing painful and requiring vascular intervention
Specialized Wound Management
Other wound types require unique care approaches:
- Burn wounds: Involve depth classification and require fluid management, pain control, and infection prevention
- Ostomy care: Protect peristomal skin from enzyme-rich output while maintaining appliance fit
- Drain management: Maintain patency, monitor output, and prevent infection or dislodgement
- Fistula care: Manage continuous output while protecting skin, often requiring pouching systems
- Fungating wounds: From cancer progression, requiring odor control, bleeding management, and psychosocial support
Mastery of diverse wound types prepares you for the breadth of tissue integrity questions on NCLEX-RN.