Clinical Focus - Pressure Injury Prevention & Care
Pressure Injuries - A Persistent Issue In Modern Healthcare
A pressure Injury can be defined as “Localised injury to the skin and/or underlying tissue, occurring over a bony prominence, as a result of Pressure or a combination of Pressure & Shear”(1). These wounds occur most frequently in individuals who have limited mobility or are unable to reposition themselves. While commonly seen in the elderly and frail, as well as individuals with Spinal Cord Injuries, they can occur in individuals of any age should they be exposed to prolonged periods of pressure and shear forces. (2)
In a recent 2018 HSE Publication ‘Pressure Ulcers A Practical Guide For Review’ Pressures areas were referred to as ‘common occurrences’ within Acute and Long Stay care setting in ireland with a mean pressure injury prevalence estimated to be at 16% and a mean incidence of 11%.(3) These figures reflect international data where a mean prevalence of 20.9% has been reported in the acute setting and 11.7% in the long stay setting. Internationally, mean incidence within acute care is reported at 18% and within long stay is reported at 6.6% (3).
A Substantial Strain on both the Individual & Health Service
Pressure Injuries pose a significant physical, psychological and financial impact on an effected individual resulting in lengthened periods care and significant increases in mortality rates directly related to the Pressure Injury. Indeed global mortality directly attributable to pressure injuries has increased by 32.7% from 2000 – 2010 (4).
From a financial perspective, pressure ulcers not only impact on the individual, but also on health services and by proxy, society as a whole. Data suggest that the management of pressure ulcers absorbs almost 4% of health care budgets in Europe (5). From an Irish perspective, a recent study (6) estimated the financial burden of wounds in general, at 6% (95%CI’s: 4% to 8%) of total public health expenditure in 2013; given the high prevalence and incidence of pressure ulcers, it is likely that these wounds significantly contribute to this expenditure.
Most pressure ulcers can be avoided, providing individuals at risk are correctly identified and appropriate measures are put into place to combat risk. Despite this, the development of pressure ulcers often arises because there has been a failure to implement appropriate prevention strategies.
For this reason it is essential that as Nurses and Carers we continue to investigate, innovate and implement care strategies that will enable us to address the significant but ultimately preventable challenges that Pressure Injuries pose for the individuals within our care.
A Word on Pressure Pressure Injury Grading
EPUAP Pressure Injury Grading
Grade 1 - Non Blanchable Erythema
- Intact skin with non-blanchable redness of a localised area usually over a boney prominence.
- Darkly Pigmented skin man not have visible blanching; its color may differ from the surrounding area.
- The area may be painful, firm soft, warmer or cooler comapred to adjacent skin.
- May be difficult to detect in individuals with dark skin tones.
- May indicate “at risk” persons ( heralding sign of risk)
Grade 2 - Partial Thickness Skin Loss
- Partial thickness loss of dermis presenting as a shallow open wound with a red-pink wound bed without slough.
- May also present as an intact or open ruptured serum filled blister.
- Presents as a shiny or dry, shallow wound without slough or bruising ( NB Bruising indicates suspected deep tissue injury)
- Grade 2 PI should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, AID or excoriation.
Grade 3 - Full Thickness Skin Loss
- Full thickness Tissue Loss. Subcutaneous fat may be visible but muscle, tendon or bone are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling.
- The depth of a Grade 3 PI varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Grade 3 Pis can be shallow. In contrast, areas of significant adiposity can develop extremely deep grade 3 Pis. Bone or Tendon is not visibly or directly palpable.
Grade 4 - Full thickness Tissue Loss
- Full thickness tissue loss with exposed muscle, tendon or bone. Slough or eschar may be present on some parts of the wound bed.
- The depth of a Grade 4 PI varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Grade 4 PIs in these arescan be shallow. Grade 4 PIs can extend into muscle and/or supporting structures (e.g. facia, tendon, or joint capsule) making osteomyelitis possible. Exposed tendon or bone is visible or directly palpable.
Ungradable - Depth unknown
- Full thickness tissue loss in which the base of the PI is covered by slough ( yellow, tan, grey, green, or brown) and/or Eschar ( tan, brown or black) in the wound bed.
- Until enough slough/eschar is removed to expose the base of the PI, the true depth , and therefor the grade cannotbe determind.
- Stable (Dry, adherent, intact with erythema or fluctiance) eschar on the heels serves as the body’s natural biological cover and should not be removed.
Suspected Deep Tissue Injury - Depth Unknown
- Purple or maroon localised area or discoloured, intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear.
- The area may be warmer or cooler as compared t adjacent tissue.
- Deep tissue injury may be difficult to detect in individuals with dark skin tone.
- Evolution may include a thin blister over a dark wound bed.
- The PiI may further involve and become convered by thin eschar.
- Deterioration may be rapid exposing additional layers of tissue even with optimal treatment.
Diagrams & Clinical PResentations
Based on National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2009, Washington DC: NPUAP cited in Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Abridged Version, AWMA; March 2012. Published by Cambridge Publishing, Osborne Park, WA.
Avoidable & Unavoidable Pressure Injuries
The majority of the evidence would suggest that through the implementation of the proper care and diligence, given the fact that Pressures Injuries are generally as a result of relatively low pressures over relatively long periods of time; the prevention of the majority of Pressure Injuries is possible and indeed diligent implementation of focused preventative protocols will at a minimum prevent the deterioration of minor injuries (Grade 1 or 2) to more serious Grade 3 and 4 Wounds. For this reason in order to effectively assess a given Pressure Injury and the associated level of care we must also indicate whether on assessment the injury is deemed Avoidable or Unavoidable.
This is an important step in the evaluation of the care and service provided so as to identify any gaps insuring that corrective and preventative measures can by then integrated into care policies and protocols.
Avoidable Pressure Injury
Avoidable means that the service user receiving care developed a pressure ulcer and the provider of care did not do one or more of the following: evaluate the service user’s skin & clinical condition and pressure ulcer risk factors; plan and implement interventions that are consistent with the service users’ needs and goals, and recognised standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate
Unavoidable Pressure Injury
Unavoidable means that the service user receiving care developed a pressure ulcer even though the provider of the care had evaluated the service user’s clinical condition and pressure ulcer risk factors; planned and implemented interventions that are consistent with the service user’s needs and goals; and recognised standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate; or the individual service user refused to adhere to prevention strategies in spite of education of the consequences of non-adherence
An Innovative Practical Aid for Pressure Injury Prevention & Care
The Prevention and/or Care of a Pressure Injury requires a truly Holistic approach to care; supported by a fully committed and integrated Team Based approach at all levels to the the provision of that care. This can be a challenge especially when levels expertise and education can vary greatly across a care team. The C.P.R.S. System has been developed to support evidence based best practice across all levels of expertise, experience and knowledge within a given care team and provide a structure that can work alongside formalised Risk Assessment processes and care tools such as Waterlow, SSKIN Bundle etc to prompt awareness and proactive care and all points of intervention to ensure effective detection, prevention and care of individuals at risk and/or currently being treated for a Pressure Injury.
The simple but familiar Mnemonic of C.P.R. has been intentionally utilised to reflect the underlying physiology of a PI ie the maintenance of oxygenated blood flow to the tissues, however in this case by mobilisation, repositioning or pressure redistribution as opposed to chest compressions. But fundamentally we are looking at achieving the same goal ” Perfusion & Oxygenation of tissue”. An additional letter “S” ( Support) has been added to reflect the requirements for an ongoing and holistic approach to care completing C.P.R.S. – Check-Protect-Report-Support.
Every interaction with a patient/resident should be seen as an opportunity to visualise and inspect the skin especially over high risk areas.
Activities such as Toileting, Washing, Showering and Repositioning must be considered opportunities to visualise and inspect all areas of the skin palpating any redness to establish whether it is Blanching or Non-Blanching
What to Check For
- General Skin Condition – Dry/Wet/Irritated
- Redness – Periodic/Persistent
- Non-Blanching Redness (Hyperemia)
- Blisters – Fluid/Blood
- Localised Heat or Coolness
- Localised Oedema (Swelling)
- Localised Induration (Hardening)
- Discoloration purplish/bluish localised areas
- Assess skin regularly –inspect most vulnerable areas
- Frequency – based on vulnerability and condition of patient
- Encourage individuals to inspect their skin where possible
- Feet should always be Checked separately.
While it is essential to inspect the skin at every opportunity it is highly recommended that a full skin check is completed and formally documented at least once every 8 to 12 hours. This may be more frequent depending on the risk profile of the individual or the presence of an active injury.
Protect Skin & Tissue
- Maintain Healthy Skin Condition.
Cleanse and dry skin properly at regular intervals.
Skin Moisturiser – (Dry Skin)
Barrier Cream – (Wet/Escoriated Skin)
NO POWDER or SUDOCREM
- Be aware of individuals with a high risk of Pressure Injury. Seated individuals are at higher risk of Sacral and Buttock that individuals cared for in bed.
- Facilitate mobilisation at every opportunity – Not every person who can not walk can not stand and nd supported standing for even short periods is highly beneficial.
- Repositioning – Tailored Documented Regimen
- Offloading – Especially Useful for Feet/Heels
- Ensure the Support Surface is appropriate to the level of risk for each individual–
Individuals with Grade 1-2 Pressure Injuries should as a minimum provision be placed on a high specification pressure redistribution or offloading device based on risk assessment and be closely observed for skin changes.
- Individuals with Grade 3-4 Pressure Injuries
- HeelsFeet?lower limb – A dedicated Offloading Device must be used as per EPUAP 2014 Guidelines.
- Sacrum/Body – As a minimum provision must be placed ona high specification foam mattress with an alternating pressure overlay or a sophisticated continuous low pressure system (Alternating Air mattress)
- The optimum wound healing environment should be created using appropriate modern dressings based on an indepth wound assessment.
Protective Dressing – Protect Fragile Skin
Report/Refer all suspect skin changes to a Nurse or Tissue Viability Specialist
- Non-Blanching Redness (Erythema) – This is technically a Grade 1 Pressure Injury
- Redness – Blanching but persistent when turning/repositioning
- Blisters – Fluid/Blood ( Possible Grade 2 or Suspected Deep Tissue Injury)
- Deterioration or changes in skin condition.
- Poor Compliance with repositioning regimen.
- Any reduction in mobility.
- If Support Surface (Bed/Mattress/Chair/Cushion) is unsuitable in reducing pressure or maintaining position.
Continuous Support & Holistic Care for Prevention & Treatment
- Maintain & Encourage Mobility – Physio Support & Mobility Aids
- Hydration – Good hydration supports good skin condition
- Nutrition – The application of the MUST assessment. Avoid Weight Loss and support with supplements were indicated. Were possible expert input from a dietician should be included.
- Continence Care – Manage changes in continence using the appropriate continence wear and Skin protection
- Wound Care – Provision of focused wound care for the treatment of active pressure injuries with regular documented assessment of wound progress.
- National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel & Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. (Cambridge Media, 2014).
- Moore, Z. E. H. & Cowman, S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2 (2014).
- Moore, Z., Johansen, E. & van Etten, M. A review of PU prevalence and incidence across Scandinavia, Iceland and Ireland (Part I). Journal of Wound Care 22, 1-7 (2013).
- Lozano, R., Naghavi, M. & et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 380, 2095-2128 (2010).
- Posnett, J., Gottrup, F., Lundgren, H. & Saal, G. The resource impact of wounds on health-care providers in Europe. Journal of Wound Care 18, 154-161 (2009).
- Gillespie, P., Carter, L., McIntosh, C. & Gethin, G. in European Wound Management Association (Bremen, Germany, 2016).
Pressure Injury Care - Product Focus
REBACARE is a uniquely comprehensive and innovative range of products that will help you address the most challenging repositioning and offloading scenarios with single product and combination options customisable to your patients individual repositioning requirements.
For more information on the REBACARE range of Products and to arrange a product evaluation contact:
Joe Mayne, Managing Director – Biofact Pharma Ltd.
Tel: +353 87 908 7506
PROLEVO – An intuitive range of Offloading and Pressure Redistribution products specifically designed for the prevention and treatment of Pressure Injuries of the Heel and Foot. The Prolevo range has been designed to specifically address the offloading requirements for Pressure Injuries of the foot outlined within the 2014 EPUAP Guidelines.
For more information on the Prolevo range of products and to arrange a product evaluation contact:
Mark Bolton, Managing Director – PRO-HEAL Ltd.
Tel: +353 83 851 6747