Protecting Patients from Pressure Injuries
Pressure injuries are a growing problem in the healthcare setting. As a healthcare provider, you know that treating pressure injuries requires time and resources. This adds to your workload and puts an increased financial burden on facilities. Most important, pressure injuries cause pain and slow patient recovery. For these reasons, it’s vital to help prevent pressure injuries with attentive care and speed healing with proper treatment. It takes much less time and resources to take the proper precautions to prevent pressure injuries than to treat them after they develop.
A complex problem
Pressure injuries are localized injuries to the skin or underlying tissue due to unrelieved pressure. This puts patients with immobility issues at greatest risk of developing pressure injuries. Other health problems can also dramatically increase their risk. Yet even under such challenging conditions, pressure injuries can be prevented if proper steps are taken. The single most important issue regarding pressure injuries is prevention. Once a deep pressure injury forms it is very hard to heal.
Steps for care
Assess each patient’s pressure injury risk upon admission and throughout the patient’s stay.
Document your findings in detail.
Prevent injuries by limiting time patients spend in one position.
Involve family members in prevention efforts from the start.
Evaluate an existing pressure injury to determine its stage.
Treat pressure injuries quickly and properly to speed healing.
Reduce risk of infection by using gloves and practicing the proper handwashing technique.
Assess patient risk upon admission
Every patient requires an initial risk assessment upon admission. This involves performing a thorough skin assessment and gathering the patient’s information. The patient’s risk factors for pressure injuries should also be listed in the assessment. Use the risk assessment tool, such as the Braden Scale or Norton Scale, approved by your facility. Be sure to document whether your patient is any of the following:
Immobile or inactive
Underweight or overweight
Malnourished or dehydrated
Ill with systemic disease, such as diabetes or anemia
Recovering from surgery
Medicated with steroids or sedatives
Sensory impaired or has an altered level of consciousness
Assess and document patient progress
Thorough assessment and proper documentation are vital for monitoring patient progress. Both should be performed during each shift. Assessment and documentation also show that you and others at your facility are taking all the appropriate steps to prevent, manage, and treat pressure injuries.
Assess with care. Properly assess each patient for pressure injuries stage. Be particularly mindful when examining for pressure injuries in patients with dark skin tones. It can be difficult to determine changes in skin color. Have a good understanding of which parts of the body are particularly prone to developing pressure ulcers, such as the heels and over the buttocks. Also know ways to decrease pressure and shear force on these areas.
Document with care. Once you’ve assessed the patient and staged the injury, document your findings. Remember to be thorough and descriptive. Doing so gives a clear account of the wound’s state and progress. Document the following:
The patient’s level of pain using your facility’s pain scale.
The length, width, and depth of the pressure injury.
The type of wound tissue present, such as slough or granulation.
If any exudate is present and its characteristics, such as if it is serosanguineous fluid. Also note the amount, color, consistency, and odor of drainage.
The presence of a tunnel or sinus tract. Also note undermining. It is extremely useful to place your gloved finger into the wound and probe. This way you can assess the depth of the wound and discover tracks that were previously not seen with a simple surface exam. You may also be able to feel bone in the base of the wound. This means a high risk for osteomyelitis, an infection of the underlying bone.
The condition of surrounding skin. Note any signs of infection, such as redness or warmth of skin, or injuries due to pressure, tape, or other causes.
Caution: Never reverse stage or “backstage” a healing pressure injury. For example, do not list a healing Stage 4 as a Stage 3. Instead, continue documenting the injury’s characteristics relative to its initial stage.
A variety of professional resources are available to help you care for and prepare your patients for discharge. Your facility may even have a skin care team that makes “skin care rounds.” Be sure to take advantage of all the resources available for preventing and treating pressure injuries. Follow your facility’s protocol for referring patients to other specialists. Some of these specialists include:
Occupational therapist or physical therapist
Doctor or surgeon
Infectious disease specialist
March 14, 2018
Agency for Healthcar Research and Quality, Patient Safety and Quality, An Evidence Based Handbook for Nurses, 2008, Bluestein, D., Pressure Ulcers: Prevention, Evaluation, and Management, American Family Physician (2008); 78(10); pp, 1186-1194, Gefen, A., Why is the heel particularly vulnerable to pressure ulcers, British Journal of Nursing (2017), Langemo, DK., Pressure Ulcers in Individuals Receiving Palliative Care: A National Pressure Ulcer Advisory Panel White Paper, Advances in Skin and Wound Care (2010) 23(2); pp. 59-72, Stephens, M., Understanding the association between pressure ulcers and sitting in adults what does it mean for me and my carers? Journal of Tissue Viability (2017)
Freeborn, Donna, PhD, CNM, FNP,Hurd, Robert, MD