A pressure injury is localized damage to the skin and underlying tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs because of intense and/or prolonged pressure.
The cost to treat pressure ulcers can be expensive; the HCUP study reported an average cost of $37,800. Cost data vary greatly, depending on what factors are included or excluded from the economic models (e.g., nursing time, support surfaces). It has been estimated that the cost of treating pressure ulcers is 2.5 times the cost of preventing them. Thus, preventing pressure ulcers should be the goal of all nurses.
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable 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; these may indicate deep tissue pressure injury.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
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) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present.
Stage 3 Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an 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 Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
Intact or non-intact skin with localized area of persistent non-blanchable 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 wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or 4).
Pressure Ulcers and Support Surfaces
Pressure ulcers (i.e. bedsores, pressure sores, decubitus ulcers) are areas of localized damage to the skin and underlying tissue. They are common in the elderly and immobile, and costly in financial and human terms. Pressure-relieving support surfaces (i.e. beds, mattresses, seat cushions etc.) are used to help prevent ulcer development and to support healing of existing pressure ulcers by offloading pressure from the wounds.
If the person is not adequately supported when lying or sitting, pressure to an area can lead to poor blood flow to the tissues, causing direct damage to cells and tissues. This sensation usually triggers a person to move, relieving the pressure. However, if a person has reduced sensation or is unable to move themselves, the continued application of pressure to an area can cause damage to the skin and soft tissue, resulting in a pressure ulcer.
Support surfaces deal with pressure in 2 ways:
(1) Immersion for Body Mass Distribution. By allowing a patient’s body to sink into the support surface, the weight and therefore the pressure is spread over a larger area. These are known as REACTIVE systems
(2) Alternating Pressure for Sequential Pressure Relief. Pressures in the cells of the support surface are changed intermittently to relieve pressure from individual areas of the body in sequence and allow tissues to recover before they bear pressure again. These are known as ACTIVE systems.
Industry Experts & the NPUAP classify support surfaces as Reactive or Active.
Almost all the Support Surfaces in America today are REACTIVE – Foam Pads, Gel Pads, Static Air Pads, Low Air Loss and Air Fluidized Systems are all REACTIVE systems. They work by Immersion. The patient sinks into the mattress like in a hammock. This often creates neck, hip, and back pain (because of the unnatural curvature of the spine and pelvis) causing the patient to be uncomfortable. This discomfort can result in lowered patient compliance and may even require pain medication to manage. In REACTIVE Systems, Pressure is redistributed for pressure reduction, but PRESSURE is CONSTANT unless the patient is moved. PRESSURE is NEVER reduced to zero.
ACTIVE systems are defined as those systems (always powered) that are designed to make periodical changes in pressure regardless of patient movement. In addition to pressure reduction, these cyclical pressure changes provide True Offloading through sequential pressure relief. This is not Immersion. The patient lies “on” the bed, not “in” the bed. The system supports the patient in a more normal alignment to help prevent pain and discomfort.
The True³ Digital System is an ACTIVE system – Pressure alternates every 2.5 minutes in the System to take pressure off of one third of your body at a time. PRESSURE is NOT CONSTANT. PRESSURE is sequentially REDUCED to ZERO.
Preventing Pressure Ulcers
“Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. When this happens, a pressure ulcer may form . . . . .”
How to Care for Pressure Ulcers
“Stage I or II sores will heal if cared for carefully. Stage III and IV sores are harder to treat and may take a long time to heal. Here’s how to care for a pressure sore at home.
Relieve the pressure on the area.
• Use special pillows, foam cushions, booties, or mattress pads to reduce the pressure. Some pads are water- or air-filled to help support and cushion the area. What type of cushion you use depends on your wound and whether you are in bed or in a wheelchair. Talk with your health care provider about what choices would be best for you, including what shapes and types of material.
• Change positions often. If you are in a wheelchair, try to change your position every 15 minutes. If you are in bed, you should be moved about every 2 hours . . . . .”
Pressure Ulcers: What You Need to Know
“Bed sores can affect people who spend a long time in one position, for example, because of paralysis, illness, old age, or frailty. Also known as pressure ulcers and pressure sores, bed sores can happen when there is friction or unrelieved pressure on one part of the body.
People who cannot make even small movements are at risk of pressure sores.
The sores can affect any part of the body, but the bony areas around the elbows, knees, heels, coccyx, and ankles are more susceptible.
Bedsores are treatable, but, if treatment comes too late, they can lead to fatal complications.
The prevalence of pressure sores in intensive care units in the United States (U.S.) is estimated to range from 16.6 percent to 20.7 percent . . . . .”