Table of Contents

Introduction

Pressure injuries, also known as bedsores or pressure ulcers, pose significant challenges in healthcare settings, particularly for bedridden or immobile patients. Effective nursing management of pressure injuries involves a multifaceted approach encompassing prevention, assessment, and treatment strategies tailored to individual patient needs. This comprehensive management not only promotes wound healing but also aims to prevent recurrence and minimize patient discomfort. In this article, we’ll delve into the key components of nursing management of pressure injuries in detail.

While terms like decubitus ulcer, pressure sore, and pressure ulcer have traditionally been used interchangeably, the National Pressure Injury Advisory Panel (NPIAP) now advocates for the term “pressure injury” due to the varying presentations these injuries may have, which might not always involve open ulceration. Pressure injuries can manifest as intact skin or as open ulcers and may cause pain (Kirman & Geibel, 2022).

The NPIAP provides a staging system for pressure injuries, which aids in their classification and management:

Stage 1 pressure injury: Nonblanchable erythema of intact skin
Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis
Stage 3 pressure injury: Full-thickness skin loss
Stage 4 pressure injury: Full-thickness skin and tissue loss
Unstageable pressure injury: Obscured full-thickness skin and tissue loss
Deep pressure injury: Persistent non-blanchable deep red, maroon, or purple discoloration.

This staging system helps healthcare professionals accurately assess and categorize pressure injuries, guiding appropriate treatment and management strategies.

Prevention

Preventing pressure injuries is paramount in nursing management. Nurses play a crucial role in identifying at-risk patients and implementing preventive measures. Strategies include regular repositioning of patients to relieve pressure on vulnerable areas, utilizing pressure-relieving support surfaces, promoting mobility and activity, maintaining optimal nutrition and hydration, and ensuring proper skin care. Additionally, educating patients, caregivers, and healthcare staff about the importance of pressure injury prevention and techniques for reducing risk is essential.

The nursing priorities for patients with pressure injuries are as follows:

Accurately assess and stage pressure injuries.
Implement effective strategies for pressure relief and redistribution.
Optimize wound care to promote healing.
Manage pain and discomfort associated with pressure injuries.
Prevent infection through proper wound hygiene and antimicrobial treatments.
Educate patients on self-care and preventive measures.
Address underlying factors contributing to pressure injuries, such as immobility or poor nutrition.
Monitor and manage complications such as cellulitis or deep tissue damage.
Collaborate with a multidisciplinary team to ensure comprehensive care.
Conduct regular reassessment and documentation of pressure injuries.

Assessment

Thorough assessment is fundamental for early detection and management of pressure injuries. Nurses conduct comprehensive skin assessments upon admission and at regular intervals thereafter. Standardized tools such as the Braden Scale or Norton Scale are utilized to assess the risk of pressure injury development. Documentation of the location, size, stage, and characteristics of any pressure injuries is crucial for monitoring progress and guiding treatment decisions. Moreover, nurses assess for signs of infection, tissue necrosis, or other complications that may impact wound healing.

Assessment for the following subjective and objective data includes:

Destruction of skin layers
- Subjective: Patient reports pain, discomfort, or changes in sensation at the site of the injury.
- Objective: Visual inspection reveals visible damage to the layers of the skin, such as redness, blistering, or open wounds.
Disruption of skin surfaces
- Subjective: Patient complains of skin breakdown, irritation, or tenderness.
- Objective: Observation of the skin shows areas of broken or damaged skin surfaces, which may appear as abrasions, ulcers, or blisters.
Drainage of pus
- Subjective: Patient reports the presence of pus-like discharge or foul odor from the wound.
- Objective: Assessment of the wound site reveals the presence of purulent drainage, which may be yellow, green, or bloody in color.
Invasion of body structures
- Subjective: Patient describes increased pain, warmth, or swelling in the affected area.
- Objective: Examination reveals signs of tissue damage extending beyond the skin layers, such as involvement of muscle, bone, or underlying structures.
Pressure ulcer stages:
- Deep tissue injury (new stage): Subjective: Patient may report localized pain or discomfort in the area.
- Objective: Inspection shows a purple or maroon area of intact skin or blood-filled blister, indicating pressure damage to underlying soft tissue.
- Stage I: Subjective: Patient may not report any symptoms initially.
- Objective: Observation reveals non-blanchable erythema of intact skin, with possible signs of warmth, edema, or discoloration.
- Stage II: Subjective: Patient may experience mild pain or tenderness.
- Objective: Examination shows partial-thickness skin loss involving the epidermis and/or dermis, presenting as an abrasion or blister.
- Stage III: Subjective: Patient may report increased pain or discomfort at the wound site.
- Objective: Assessment reveals full-thickness skin loss with damage to subcutaneous tissue, potentially with slough or undermining present.
- Stage IV: Subjective: Patient may experience severe pain or deep tissue tenderness.
- Objective: Examination shows extensive destruction of tissue, with involvement of muscle, bone, or supporting structures, often accompanied by undermining and tunneling.
- Unstageable: Subjective: Patient may report severe pain or pressure at the wound site.
- Objective: Evaluation reveals full-thickness tissue loss obscured by slough or eschar, making it difficult to determine the depth of the ulcer.

Treatment

The treatment of pressure injuries requires a tailored approach based on the wound’s characteristics and the patient’s overall health status. Nurses prioritize offloading pressure from affected areas through appropriate positioning techniques and the use of specialized support surfaces. Advanced wound care strategies such as moist wound healing, debridement, and selection of appropriate dressings are implemented to promote tissue regeneration and prevent infection. Pain management is also a key aspect of treatment, with nurses employing pharmacological and non-pharmacological interventions to alleviate discomfort. Addressing underlying factors contributing to pressure injury development, such as malnutrition or immobility, is integral to the treatment plan. Collaborating with interdisciplinary team members, including wound care specialists, dieticians, and physical therapists, ensures a holistic approach to patient care.

Education and Support

Patient and caregiver education is essential for successful pressure injury management. Nurses provide comprehensive education on wound care techniques, preventive measures, and signs of complications. They also offer emotional support and encouragement to patients coping with the physical and psychological impacts of pressure injuries. Additionally, nurses facilitate access to community resources and support groups to enhance patient and caregiver coping skills and promote self-management.

Nursing goals and expected outcomes may include:

Ensure the client receives stage-appropriate wound care and effectively manages risk factors to prevent additional ulcers.
Facilitate the healing of pressure injuries and implement measures to reduce pressure on affected areas.
Educate the client and caregiver on home care practices including nutrition, pressure relief techniques, wound care, and incontinence management.
Assist the client and caregiver in verbalizing their ability to cope with the situation and provide necessary support and monitoring.
Support the client in maintaining a stable weight or achieving progressive weight gain towards established goals.
Ensure the client is free from malnutrition and understands the importance of adequate nutritional intake.
Assist the client in identifying individual barriers to adequate food intake and understanding the impact of malnutrition on pressure injury development.
Encourage the client to actively participate in interventions aimed at stimulating appetite and increasing dietary intake.
Implement measures to prevent the further development of avoidable pressure injuries.

Therapeutic interventions and nursing actions for patients with pressure injuries may include:

Assessing and Staging Pressure Injuries:
- Assess specific risk factors for pressure injuries, considering factors such as prolonged pressure, shearing forces, friction, moisture, and nutritional status.
- Evaluate the client’s age and general skin condition, recognizing that older adults may have less elastic and thinner skin, predisposing them to skin impairment.
- Assess nutritional status, including weight, serum albumin levels, and history of weight loss, as malnutrition can hinder wound healing and tissue repair.
- Investigate the client’s history of chronic diseases, such as diabetes mellitus or cardiovascular disease, which can increase vulnerability to pressure injuries.
- Conduct a thorough skin assessment upon admission and daily thereafter, noting any changes or signs of skin breakdown.
- Consider any history of radiation therapy, as irradiated skin may be more susceptible to breakdown.
- Evaluate the client’s awareness of pressure sensation, as decreased sensation can lead to prolonged pressure on vulnerable areas.
- Assess for fecal and urinary incontinence, which can contribute to skin breakdown and moisture-related complications.
- Evaluate the client’s mobility and ability to shift weight or change position, as immobility is a significant risk factor for pressure injuries.
- Consider environmental factors such as excessive perspiration, high humidity, or wound drainage, which can exacerbate skin maceration and breakdown.

2. Assessing Shear and Friction:

Evaluate the amount of lateral pressure (shear) and rubbing (friction) experienced by the client’s skin, particularly on areas prone to pressure injuries such as the sacrum, scapulae, heels, and elbows.
Recognize that shear forces can result from various factors such as skin-sheet friction, positioning in semi-Fowler’s position, repositioning, and lifting sheets.
Be aware that trauma leading to deepithelialization or skin tears can increase vulnerability to bacterial contamination and skin damage.

3. Assessing Surface:

Assess the surface on which clients spend the majority of their time, such as mattresses for bedridden clients or cushions for those in wheelchairs.
Ensure clients have appropriate pressure reduction or relief devices to minimize the risk of skin breakdown and tissue ischemia.

4. Assessing Bony Prominences:

Evaluate the skin over bony prominences including the sacrum, trochanters, scapulae, elbows, heels, inner and outer malleoli, inner and outer knees, and back of the head.
Recognize that these areas are at the highest risk for pressure injuries due to compression against hard surfaces, leading to tissue ischemia.

5. Using Objective Assessment Tools:

Utilize standardized tools such as the Braden scale, Norton scale, or Waterlow scale for objective assessment of pressure ulcer risk.
Consider factors such as activity, mobility, moisture, nutrition, sensory perception, and friction when assessing risk.

6. Assessing Pain:

Evaluate the client’s level of pain, particularly related to dressing changes and procedures.
Consider prophylactic pain medication for comfort during wound care.
Recognize that while pain may be present at the injury site, it may also be absent due to factors such as paralysis or critical condition.

7. Assessing and Staging Pressure Injuries:

Perform thorough assessment and staging of pressure injuries to determine appropriate treatment plans.
Recognize that staging reflects the extent of tissue involvement, from the epidermis to deeper structures.
Understand that accurate staging may be challenging, particularly in cases of covered ulcers or in clients with darkly pigmented skin.
Utilize standardized staging systems such as those provided by the National Pressure Injury Advisory Panel (NPIAP) to guide assessment and treatment.

Assessing the condition of the wound or wound bed involves several key aspects:

Presence of Necrotic Tissue:

Necrotic tissue must be identified and removed for proper wound healing to occur.
Necrotic tissue can vary in appearance, including black, brown, leathery, hard, shiny, thin, tough, or white.
Accurate staging of the wound cannot be achieved until necrotic tissue is removed.

Color:

The color of the wound bed indicates tissue viability and oxygenation.
Viable tissue appears pink or red and is moist.
Eschar may be present, appearing white, gray, or yellow in stage II and III ulcers, and black in stage IV ulcers.
Deep tissue injury presents as persistent nonblanchable deep red, maroon, or purple discoloration.

Odor:

Odor may arise from infection within the wound or from necrotic tissue.
It is important to distinguish between odors caused by wound or exudate and those caused by local wound care products.
Foul odor or discharge may indicate a serious infection.

Viability of Bone, Joints, or Muscle:

In stage IV pressure injuries, bone, joints, or muscle may be visible at the base of the ulcer.
Wounds may exhibit multiple stages or characteristics, requiring careful assessment.
Muscle is the least resistant to pressure and may become necrotic before the skin breaks down.

Measurement of Ulcer Size and Presence of Undermining:

Measure the length, width, and depth of the ulcer to accurately assess its size.
Note the presence of undermining, which may extend beyond the visible wound edges and indicate a larger wound cavity.

Assessment of Wound Edges and Surrounding Tissue:

Evaluate the condition of wound edges and surrounding tissue, which may range from healthy to impaired.
Healthy tissue is necessary for proper adhesion of local wound care products and helps demarcate the boundaries of the pressure injury.
Epibole or rolled wound edges may be present in stages 3 and 4 pressure injuries.

Assessment of Wound Exudate:

Differentiate between normal wound exudate and pus, which indicates infection.
Wound exudate may contain serum, blood, and white blood cells, appearing clear, cloudy, or blood-tinged.
Excessive drainage may require frequent dressing changes.

Assessment of Ulcer Healing using PUSH Tool:

Utilize the Pressure Ulcer Scale for Healing (PUSH) tool to standardize the measurement of wound healing.
The PUSH tool quantifies wound size, tissue type, and exudate amount to monitor healing progress accurately.

Wound care and promoting skin integrity involve several key strategies:

Encourage the use of pressure-relieving devices:
- Specialized mattresses, cushions, heel troughs, and other devices help distribute pressure evenly across the body, reducing the risk of pressure injuries.
- These devices create areas of low pressure that alternate with areas of higher pressure, promoting blood flow and preventing tissue damage.
- Support surfaces may be dynamic, requiring an energy source to alternate pressure points, or static, redistributing pressure over a large surface area without an energy source.
Encourage frequent repositioning of the client:
- Repositioning the client frequently helps distribute pressure evenly, decreasing the risk of pressure injuries.
- Turning and repositioning every two hours, even with specialty surfaces or beds, remains essential for prevention and treatment.
- Clients capable of shifting weight every 10 minutes should be encouraged to do so.
Ensure the client maintains a well-balanced diet:
- Consult a dietitian to develop an individualized nutrition plan based on the client’s needs and medical history.
- Adequate caloric intake is crucial for healing pressure injuries, as malnutrition is a reversible contributing factor.

3.1. Protein:

Protein is essential for tissue building and repair, fluid balance, blood clotting, and immune function.
Good sources include lean meats, poultry, fish, eggs, beans, and dairy products.

3.2. Vitamin C:

Vitamin C aids in collagen synthesis, strengthening and repairing tissues.
Sources include citrus fruits, berries, tomatoes, and leafy green vegetables.

3.3. Zinc:

Zinc is important for wound healing and immune function.
Foods rich in zinc include oysters, beef, chicken, beans, eggs, and nuts.

3.4. Iron:

Iron is vital for oxygen transport in the blood and collagen formation.
Sources of heme iron include lean meats, poultry, and fish, while non-heme iron sources include beans, nuts, and leafy green vegetables.

Promoting optimal nutrition status is crucial in the prevention and treatment of pressure injuries. Here are key steps to achieve this:

Perform Nutrition Screening:
- Conduct a nutrition screening on clients with pressure injuries using a validated screening tool.
- This screening helps identify clients at risk of malnutrition, guiding further assessment by a registered dietitian.
Obtain Weight and BMI:
- Obtain the client’s weight and calculate Body Mass Index (BMI) upon admission.
- Weight loss and low BMI are associated with impaired wound healing, while obesity increases the risk of pressure injuries.
Review Dietary Intake:
- Review the client’s usual daily caloric intake and dietary choices.
- Identify strengths and weaknesses in the diet to adjust individual nutritional needs and provide education.
Assess Body Composition:
- Identify the client’s body composition as an independent risk factor for malnutrition and associated comorbidities.
- Monitor changes in body mass over time, particularly in immobile individuals at risk of sarcopenia and sarcopenic obesity.
Establish Weight Goals:
- Collaborate with a registered dietitian to establish a weight goal for the client.
- Provide 30 to 35 kcal/kg of body weight per day for malnourished or at-risk clients with pressure injuries, as recommended by EPUAP/NPIAP/PPPIA.

Documentation

Accurate and detailed documentation is critical for effective pressure injury management. Nurses maintain comprehensive records of pressure injury assessments, interventions, and outcomes. This includes documenting wound measurements, characteristics, and progress over time. Clear communication with the healthcare team ensures continuity of care and coordination of services, ultimately optimizing patient outcomes.

In conclusion, nursing management of pressure injuries requires a proactive and multifaceted approach that addresses prevention, assessment, treatment, education, and documentation. By implementing evidence-based strategies and collaborating with interdisciplinary team members, nurses can effectively manage pressure injuries, promote wound healing, and improve patient quality of life. With a focus on patient-centered care and a commitment to best practices, nurses play a pivotal role in mitigating the impact of pressure injuries and optimizing patient outcomes in healthcare settings.