History
The clinical presentation of pressure injuries (pressure ulcers) can be deceiving to the inexperienced observer. Soft tissue, muscle, and skin resist pressure to differing degrees. Generally, muscle is the least resistant and will become necrotic before skin breaks down. Also, pressure is not equally distributed from the bony surface to the overlying skin; it is greatest at the bony prominence, decreasing gradually toward the periphery. A small area of skin breakdown may represent only the tip of the iceberg, with a large cavity and extensive undermining of skin edges beneath.
In the initial evaluation of a patient with pressure injury, the following important information should be obtained from the history:
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Overall physical and mental health, including life expectancy
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Previous hospitalizations, operations, or ulcerations
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Diet and recent weight changes
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Bowel habits and continence status
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Presence of spasticity or flexion contractures
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Medications and allergies to medications
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Tobacco, alcohol, and recreational drug use
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Place of residence and the support surface used in bed or while sitting
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level of independence, mobility, and ability to comprehend and cooperate with care
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Underlying social and financial support structure
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Presence of specific cultural, religious, or ethnic issues
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Presence of advanced directives, power of attorney, or specific preferences regarding care
Information related to the current pressure injury should also be obtained, particularly with regard to the following:
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Pain - Although pain may be present at the injury site, it is more commonly absent because the patient either is paraplegic is in critical condition and unable to acknowledge pain
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Foul odor or discharge - This could be a sign of a more serious infection at the injury site
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Natural history of the present pressure injury - This would include the length of time the injury has been present, the circumstances under which the ulcer developed, and any local treatments currently or previously employed
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Associated medical cause for the injury (eg, paraplegia, quadriplegia, spina bifida, immobilization in hospital, or multiple sclerosis)
A complete review of systems, including the presence of fevers, night sweats, rigors, weight loss, weakness, or loss of appetite, should be carried out.
Physical Examination
A thorough physical examination is necessary to evaluate the patient’s overall state of health, comorbidities, nutritional status, and mental status. The patient’s level of comprehension and extent of cooperation dictate the intensity of nursing care that will be required. The presence of contractures or spasticity is important to note and may help identify additional areas at risk for pressure ulceration.
After the general physical examination, attention should be turned to the pressure injury. Adequate examination of the wound may necessitate the administration of intravenous (IV) or oral pain medications to ensure patient comfort. Chronic pain may be present among these patients and may be exacerbated by examination ulcer.
Many classification schemes have been developed to define the severity of pressure ulcers. [59] For a considerable period, the most widely accepted approach was that of Shea, which was modified and subsequently refined by the National Pressure Ulcer Advisory Panel (NPUAP). [60] In April 2016, the NPUAP (now known as the National Pressure Injury Advisory Panel [NPIAP] since November 2019) announced an updated version of its staging system, along with a change in preferred terminology from pressure ulcer to pressure injury. [1, 2]
The NPIAP system consists of four main stages of pressure injury but is not intended to imply that all pressure injuries follow a standard progression from stage 1 to stage 4 or that healing pressure injuries follow a standard regression from stage 4 to stage 1 to a healed wound. Rather, the system is designed to describe the degree of tissue damage observed at a specific time of examination and is meant to facilitate communication among the various disciplines involved in the study and care of patients with these lesions.
The categories specified in the current NPIAP staging system are as follows [2] :
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Stage 1 pressure injury - Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin; presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes; color changes do not include purple or maroon discoloration, which may indicate deep tissue pressure injury
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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) and deeper tissues are not visible, and 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
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Stage 3 pressure injury - Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present; slough or eschar may be visible; the depth of tissue damage varies by anatomic location; areas of significant adiposity can develop deep wounds; undermining and tunneling may occur; fascia, muscle, tendon, ligament, cartilage, and bone are not exposed
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Stage 4 pressure injury - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer; slough or eschar may be visible; epibole (rolled edges), undermining, and tunneling often occur; depth varies by anatomic location
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Unstageable pressure injury - Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; if slough or eschar is removed, a stage 3 or 4 pressure injury will be revealed
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Deep tissue pressure injury - Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister; pain and temperature change often precede skin color changes; discoloration may appear differently in darkly pigmented skin; the injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface
Such staging is only a small part of the initial assessment. The injury location, the size of the skin opening (if present), and the presence of any surrounding maceration or induration must be accurately recorded. The presence of multiple pressure injuries prompts a search for interconnecting tracts with overlying skin bridging that may not be readily apparent. The presence or absence of foul odors, wound drainage, and soiling from urinary or fecal incontinence provides information about bacterial contamination and the need for debridement or diversionary procedures.
Complications
Complications fall into one of two categories: complications of chronic pressure injury (see below) and complications of reconstruction (see Treatment).
Complications of chronic injury include the following:
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Malignant transformation
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Autonomic dysreflexia
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Osteomyelitis
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Pyarthrosis
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Urethral fistula
Malignant transformation
The most serious complication of chronic ulceration is malignant transformation or degeneration (see the images below), also referred to as Marjolin ulceration. Although Marjolin initially described malignant transformation of a chronic scar from a burn wound, the term Marjolin ulcer has been commonly applied to the malignant transformation of any chronic wound, including pressure injuries, osteomyelitis, venous stasis ulcers, urethral fistulas, anal fistulas, and other traumatic wounds. [61]
Heaps of verrucous white tissue around the ulcer suggest malignant transformation, as observed with Marjolin ulcers.
Close-up view of area with heaps of verrucous white tissue around the ulcer, the presence of which suggests malignant transformation (as observed with Marjolin ulcers).
Histologically, this malignant transformation is a well-differentiated squamous cell carcinoma [62] ; however, its behavior is very aggressive in pressure injuries, considerably more so than in burns or osteomyelitis. [63, 61] There is a high likelihood of nodal metastasis at the time of diagnosis. Any long-standing, nonhealing wound should alert the examiner to the need for biopsy.
Marjolin ulcers arising from burns or osteomyelitis have been treated with wide local excision, amputation, and lymph node dissection. Because pressure injury carcinoma is substantially more aggressive, more radical treatment (eg, hemicorporectomy and regional node dissection) is required if a cure is to be effected. [63, 61]
The actual rate for malignant transformation of a pressure injury is not known but can be assumed to be low, in that only 18 cases have been described in the literature to date. Although apparently rare, pressure ulcer carcinoma is highly lethal: 12 of the 18 known patients died within 2 years.
Autonomic dysreflexia
Autonomic dysreflexia is a disordered autonomic response to specific stimuli. It includes sweating and flushing proximal to the injury, nasal congestion, headache, intermittent hypertension, piloerection, and bradytachycardia. Patients with midthoracic spinal cord lesions are most prone to this response. When autonomic dysreflexia is suggested, the patient is first positioned with the head up and monitored for changes in heart rate and blood pressure. Then, the precipitating stimulus must be removed.
The most common precipitating cause of autonomic dysreflexia is bladder distention, which is treated by inserting a Foley catheter or irrigating an already placed Foley catheter to remove blockage. Rectal examination to evaluate for fecal impaction should be considered. Nifedipine, hydralazine, or topical nitroglycerin may be administered to stabilize blood pressure. If autonomic dysreflexia does not respond to these measures, spinal anesthesia may be required.
Osteomyelitis
Foremost in the treatment of osteomyelitis is the removal of all nonviable bone, down to bone that bleeds bright red. [64] In the reconstruction of reconstructing pressure injuries associated with osteomyelitis, it is important to use bone that is in the base flaps and has a muscle component. The muscle is placed over this bone after appropriate bone debridement. The flap reconstruction can be performed at the same time as the bone debridement. A 6-week course of IV antibiotics is then administered.
Pyarthrosis
Pyarthrosis of the hip joint can occur with communication of ischial or trochanteric ulcers. Often, the femoral head contains osteomyelitis, which necessitates its removal. The Girdlestone arthroplasty procedure has been employed in this situation (ie, hip pyarthrosis), including removal of the femoral head and reconstruction of this space with the vastus lateralis muscle flap (see the image below). [65]
Illustrated is Girdlestone arthroplasty for femoral head osteomyelitis pyarthrosis of hip joint. Femoral head is removed, and hip joint space is reconstructed with vastus lateralis muscle flap.
Sepsis
Pressure injuries do not cause sepsis. In patients who present with sepsis and pressure injuries, the sepsis is usually caused by a urinary tract infection. These wounds are almost always open to drain and therefore do not constitute debridement emergencies. Only on rare occasions are these injuries entirely occluded by a thick leathery eschar that prevents open drainage. In these cases, debridement is required to facilitate drainage and prevent systemic infection. In general, patients do not die of pressure injuries, but they can die with them.
Urethral fistula
Pressure injuries can also erode into the urethra (see the images below). Treatment of this complication (ie, urethral fistula) involves urinary diversion. Pressure injury reconstruction can be considered once the fistula has healed.
Patient has urethral fistula within his pressure ulcer. When he performs Valsalva maneuver, urine leaks through this opening.
Close-up view in patient who has urethral fistula within his pressure ulcer. When he performs Valsalva maneuver, urine leaks through this opening.
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Advanced sacral pressure ulcer shows effects of pressure, shearing, and moisture.
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Heel pressure ulcer.
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Small sacral pressure sores can be reconstructed with the inferior-based skin rotation flap, with or without the superior gluteus maximus myocutaneous flap.
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Sacral pressure ulcer before and after flap closure.
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Heaps of verrucous white tissue around the ulcer suggest malignant transformation, as observed with Marjolin ulcers.
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Close-up view of area with heaps of verrucous white tissue around the ulcer, the presence of which suggests malignant transformation (as observed with Marjolin ulcers).
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Pressure ulcers of lateral aspect of right foot.
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Radical bursectomy is performed by placing methylene blue–moistened sponge in bursa and excising pressure ulcer circumferentially, removing all granulation tissue, even from wound base.
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With gluteal thigh flap, superiorly based flap is elevated, with inferior gluteal artery located between greater trochanter and ischial tuberosity as its axis.
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Gluteal thigh rotation flap is raised as fasciocutaneous flap superiorly to gluteal crease.
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Gluteal thigh flap may be raised to include inferior portion of gluteus maximus, which increases arc of rotation to allow flap also to be used to reconstruct sacral defects.
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Small sacral pressure ulcer reconstructed with inferiorly based skin rotation flap.
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Small sacral pressure ulcer reconstructed with inferiorly based skin rotation flap.
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Landmarks for superior gluteal artery, on which superior gluteus maximus muscle flap is based, include posterior superior iliac spine and ischial tuberosity.
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Superior and inferior gluteal arteries branch from internal iliac superior and inferior arteries to piriformis approximately 5 cm from medial edge of origin of gluteus maximus from sacrococcygeal line.
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When superior portion of gluteus maximus is used as flap, it is elevated in lateral-to-medial direction to avoid injury to superior gluteal artery. Insertion of superior portion of gluteus maximus into iliotibial tract is released. Harvesting entire length of muscle may be necessary to allow rotation or turnover into defect without tension.
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V-Y flaps can be based superiorly or inferiorly or on entire gluteus maximus.
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Larger sacral ulcers require use of bilateral flaps, such as bilateral V-Y advancement flaps.
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Skin paddle is harvested 10 cm in width and designed over muscle along axis from anterior superior iliac spine to lateral tibial condyle.
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Inferior limit of cutaneous territory can be extended to 6 cm above knee and 25-35 cm in length. Lateral femoral circumflex artery can be found approximately 6-8 cm inferior to anterior superior iliac spine.
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Patient required reconstruction of extremely large pressure ulcer with fillet total thigh flap procedure.
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Illustrated is Girdlestone arthroplasty for femoral head osteomyelitis pyarthrosis of hip joint. Femoral head is removed, and hip joint space is reconstructed with vastus lateralis muscle flap.
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Patient has urethral fistula within his pressure ulcer. When he performs Valsalva maneuver, urine leaks through this opening.
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Close-up view in patient who has urethral fistula within his pressure ulcer. When he performs Valsalva maneuver, urine leaks through this opening.
Tables
Surface |
Advantages |
Disadvantages |
Air |
Low maintenance; inexpensive; multipatient use; durable |
Can be punctured; requires proper inflation |
Gel |
Low maintenance; easy to clean; multipatient use; resists puncture |
Heavy; expensive; little research |
Foam |
Lightweight; resists puncture; no maintenance |
Retains heat and moisture; limited life |
Water |
Readily available in community; easy to clean |
Requires heater; transfers are difficult; can leak; heavy; difficult to maintain; procedures difficult |
Dynamic overlays |
Easy to clean; moisture control; deflates for transfers; reusable pump |
Noisy; can be damaged by sharp objects; requires assembly; requires power |
Replacement mattresses |
Reduced staff time; multipatient use; easy to clean; low maintenance |
High initial cost; may not control moisture; loses effectiveness |
Low air loss |
Head and foot of bed can be raised; less frequent turning required; relieves pressure; reduces shear and friction; moisture control |
Noisy; expensive; transfers are difficult; requires energy source; restricts mobility; requires skilled setup; rental charge |
Air fluidized |
Reduces shear and friction; lowest interface pressure; low moisture; less frequent turning required |
Expensive; noisy; heavy; dehydration and electrolyte imbalances can occur; may cause disorientation; transfers are difficult; hot |
Major Dressing Type |
Key Performance Characteristics |
Alginates (sheets and fillers) |
Exudate absorption; obliteration of dead space; autolytic débridement |
Foams (sheets and fillers) |
Obliteration of dead space; retention of moisture; exudate absorption; mechanical débridement |
Gauzes (woven and nonwoven) |
Obliteration of dead space; retention of moisture; exudate absorption; mechanical débridement |
Hydrocolloids (wafers and fillers) |
Occlusion; retention of moisture; obliteration of dead space; autolytic débridement |
Hydrogels (sheets and fillers) |
Retention of moisture; autolytic débridement |
Transparent films |
Occlusion; retention of moisture; autolytic débridement |
Wound fillers |
Obliteration of dead space; exudate absorption; retention of moisture; autolytic débridement |
Wound pouches |
Exudate control |
Area of Comparison |
Norton Scale |
Braden Scale |
Assessment criteria |
Physical condition; mental condition; activity; mobility; incontinence (score ≥12 is at risk) |
Activity; mobility; sensory perception; moisture; nutrition; friction; shear |
Attributes |
Tested on elderly persons in hospital settings |
Evaluated in diverse sites (eg, medical-surgical, intensive care units, nursing homes) |
Replications |
Tested extensively |
Tested extensively |
Reliability |
Not available |
Good interrater reliability |
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- Overview
- Presentation
- Workup
- Treatment
- Approach Considerations
- General Measures for Optimizing Medical Status
- Pressure Reduction
- Wound Management
- Principles of Surgical Intervention
- Surgical Débridement
- Options for Wound Closure
- Surgical Management of Specific Pressure Injury Types
- Postoperative Care
- Complications
- Activity
- Prevention
- Consultations
- Long-Term Monitoring
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- Medication
- Questions & Answers
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