Pressure injuries, also known as bedsores, are common. This is an injury to the skin and the tissues under it. The injuries are due to prolonged pressure on the skin. This happens when you are sitting on a wheelchair or lying on the bed for a prolonged period of time. Blood circulation is depleted in the tissues; thus, injuries happen. This will result in tissue death.
It often develops in the bony areas of the body of patients who are unable to move on their own, such as those who are unconscious and unable to sense pain. Examples of these areas are tailbone, heels, ankles, and hips.
Contributing factors for pressure injuries:
- Minimal movement
- Overweight or underweight
- No control over bowel and bladder
- Decreased sensation in a particular area; examples are your tailbone when lying down in a prolonged period of time
- Lying down or sitting down in one position
- Patients who have spinal cord injury; also with paralysis, stroke, neurologic disorders, and decreased mental awareness
Daily hygiene is important, especially when the patient is not able to perform activities of daily living. As a nurse, assess the following areas where pressure injuries may develop:
- Shoulders and Shoulder blades
- Back of the head
Signs and Symptoms
- Pus-like draining
- Tender areas
- Change in skin temperature: some areas are cool, some areas are warm to touch
- Unusual change in skin color or texture
- Bone and joint infections
Stages of Pressure Injuries
The stages of pressure injuries are based on the severity, characteristics, and depth. The damage on the skin may range from unbroken, reddish skin to deep injury, involving muscles and bones. The National Pressure Ulcer Advisory Panel (NPUAP) identified the following stages:
- Stage 1: Skin with non-blanching erythema, usually over a bony area
- Stage 2: Partial-thickness skin loss of the epidermis and some parts of the dermis. It is characterized by a shallow ulcer with red-pink color. Necrotic tissue or slough is not present. Blisters that are serum-filled (open or enclosed) are present.
- Stage 3: Epidermis and dermis are gone or damaged. Also, there is full-thickness skin loss. The damage extends to the fascia. Subcutaneous fat is visible. Slough, tunneling, or undermining is present.
- Stage 4: Damage to the bone, necrotic tissues present. Noticeable full-thickness skin loss.
- Deep tissue pressure injury: Damage to underlying soft tissue. Discoloration of the skin is purple or maroon-red in color. Blood filled blister is present. Skin changes include firmness, pain, and bogginess. Also, it can have different temperatures as compared to the other areas of the skin.
- Unstageable: Area filled with a slough or an eschar. The depth of damage is not estimated until necrotic tissues are removed.
- Reducing pressure: repositioning and the use of support surfaces
- Wound care: use a gentle cleanser to clean the wound and pat the area dry. Use of saline solution or saltwater for open sores every dressing changes. The other way is to put a bandage that keeps the wound moist.
- Removing damaged tissues: this process is removing tissues that are damaged or debridement. With this process, the wound will heal faster.
- Use of medication for pain
- Healthy diet: good nutrition can help with wound healing.
- Surgery: the surgery that is being done is also known as “flap surgery”. This is a surgical repair by the use of a pad of skin, muscle, or tissue. The purpose is to cover the wound or to add a cushion to the affected bone.
Nursing Interventions for Pressure Injuries
- Encourage the patient to move around to enhance blood circulation to the tissues.
- Change position often every 2 hours or as recommended.
- When bladder and bowel are not controlled, change the underwear often. Keep the site clean and apply an ointment such as A+D ointment to keep the area dry.
- If the skin is cracked or has an open sore, use special dressings.
- Assist the patient in lifting himself if possible. When the patient is in a wheelchair, ask them to push their body up by pushing the chair arms.
- Educate how to use a special chair that can be tilted to allow relief from pressure.
- Inform patients of the importance of selecting cushions and mattresses that relieve pressure.
- Adjust your patient’s bed elevation at the head area about 30 degrees. In this way, shearing is prevented.
- Educate the patient to verbalize his feelings. In this way, you encourage the patient to lessen his anxiety.