Wound Series Part 3: Pressure Ulcers and Injuries-Risk Factors, Diagnosis, Staging, Management

Pressure ulcers have been known as "bedsores" for hundreds of years. Historically, the term decubitus ulcer or decubiti has also been used to describe these wounds related to pressure or immobility. The term "pressure ulcer" was replaced by "pressure injury" in the 2016 Pressure Injury Staging System by the National Pressure Injury Advisory Panel (NPIAP) and Pan Pacific Pressure Injury Alliance (PPPIA). The NPIAP defines a pressure injury as "localized damage to the skin or underlying soft 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 due to intense or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue" (Edsberg et al., 2016).

Avoidable facility-acquired PUs are recognized internationally as a quality-of-care indicator for healthcare organizations (Office of Disease Prevention and Health Promotion [ODPHP], 2022; Agency for Healthcare Research and Quality [AHRQ], 2023; Centers for Medicare and Medicaid [CMS], 2022). Many healthcare organizations have adopted the new "pressure injury" terminology as well as the updated staging terminology (stages 1-4, unstageable, deep tissue pressure injury [DTPI], medical device-related pressure injury, and mucosal membrane pressure injury). The degree of tissue damage in PUs is typically classified by the NPIAP staging system (JCAHO, 2022). CMS changed its terminology to "pressure ulcers/injuries" for skilled nursing facility (SNF) quality reporting in 2018 (CMS, 2019). However, coding systems such as the International Statistical Classification of Diseases and Related Health Problems – version 10 (ICD-10) continue to use the pressure ulcer term (L89 codes). For this educational course, we will use the term pressure ulcer (PU) without disrespecting the NPIAP.

PUs can have devastating financial implications. Whittington & Briones estimated annual medical costs in the United States associated with treating PUs exceed 5 billion dollars annually. Fogerty et al. (2008) estimated this cost to be higher at $10,845 per patient, exceeding 18.5 billion dollars annually. They also concluded that treating stage 3 and stage 4 hospital-acquired PUs accounts for 58% of national costs (Padula & Delarmente, 2019). Furthermore, studies suggest preventing a PU costs less than treating it (Demarré et al., 2015). Individuals with PUs have higher mortality rates and up to five-fold increased hospital length of stay. Medicare estimated each PU added $43,180 in costs to a hospital stay, while AHRQ estimated the potential cost of individual patient care related to PUs ranging from $20,900 to $151,700 per PU (AHRQ, 2017).

Historically, PUs have been described in medical literature since at least the 1500s, when Fabricius Hildanus first documented his hypotheses of the causes and characteristics of bedsores. He highlighted the role of "internal supernatural" and "external natural" factors that interrupt the supply of blood and nutrients to tissue as causes of bedsores. French surgeon de la Motte identified mechanical pressure and incontinence as key factors in developing PUs in 1722 (Defloor, 1999). Major risk factors for PU development include increased age, impaired mobility, decreased physical activity, poor nutrition, urinary or fecal incontinence, and sensory impairment. Other studies have identified additional risk factors, including smoking status, diabetes mellitus (DM), coronary artery disease (CAD), intensive care unit (ICU) stay greater than three days, ventilator dependency, pneumonia, sepsis, obesity, surgery, female gender, vasopressor agents, and peripheral vascular disease (PVD) (Cowan et al., 2012; Tschannen & Anderson, 2020; Cox et al., 2022).

Most PUs are considered to be avoidable and preventable. An "avoidable" PU means that the patient developed a PU and the facility or healthcare providers did not perform (or document) one or more of the following: evaluate the patient's/resident's clinical condition and PU risk factors; define and implement interventions that are consistent with resident needs, resident goals and recognized standards of practice; monitor and evaluate the impact of the interventions, or revise the interventions as appropriate. There may be a few instances where PUs are unavoidable. "Unavoidable" means the patient/resident developed a PU although the facility and healthcare providers had evaluated (and documented) the resident's clinical condition and PU risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate – all within a timely manner (Scarborough, 2018).Kennedy ulcers (a specific type of PU often seen at the end of life due to organ/system failure) are one example of "unavoidable" PUs.

Etiology of Pressure Sores

Diagnosing PUs depends on assessing possible pressure, shear, and moisture-related etiological factors and the location of the tissue damage. The first question in your mental wound assessment "checklist" should be: "Is it over a bony prominence?" While PUs may develop over any bony prominence on the body, the sacrum, coccyx, buttocks, and heels of the feet are the most prevalent sites. Other common locations may include greater trochanters, ischial tuberosities, ankles, knees, elbows, scapulas, shoulders, and the occiput (IQWIG, 2018). In addition, a pressure-related injury may also be related to devices such as oxygen tubing, cervical collars, endotracheal tubes, oxygen saturation monitor probes, drain tubes, foley catheters, etc. Device-related PUs may be observed over the ears, around the urethral opening of the genitals, or in other soft tissue locations not associated with a bony prominence (NICE, 2015).

Furthermore, this type of device-related injury may cause full-thickness tissue damage, which is difficult to stage because, as in the case of the ears, there is no subcutaneous tissue evident. A very shallow wound on the ears or nose may result in the exposure of cartilage (full-thickness wound) without the involvement of muscle, tendon, or bone. Again, it is important to note that while the onset of PU is associated with unrelieved pressure, it can also be caused by a combination of pressure, friction, and shearing forces. Evaluating these potential forces (head of the bed raised for long periods, patient sliding down in the bed, chair transfers, improper overhead sling positioning, etc.) is imperative when assessing your patient's skin integrity risks.

The approach to managing PUs should always focus on PREVENTION. If the patient develops pressure-related injury (despite preventive measures), then evidence-based practice related to wound healing should be administered but always with PREVENTION in the treatment plan. Healthcare providers should also prevent the PU from deteriorating or worsening to a deeper stage. Evidence suggests that offloading and pressure reduction/redistribution should be a primary goal of treating PUs and eliminating shearing and friction forces. Addressing other key contributing or risk factors is also critical. Knowing what intrinsic and extrinsic factors contribute to skin breakdown is important. Intrinsic factors such as age, immune function, nutrition, and disease states (comorbid conditions) should be considered. Extrinsic factors such as dry skin, friction, transfer equipment, medications, and moisture should also be addressed. The scientific literature suggests PU prevention (PUP) "bundles" may be helpful (Rivera et al., 2020). A PUP or skin bundle is typically a group of interventions or evidence-based PUP strategies that are implemented as a package in a healthcare facility or unit. Components may include but are not limited to standardized staff education, competency check-offs, patient/caregiver education, risk assessment tool(s), preventive interventions by the level of risk, turning schedules, prophylactic dressings, specialized seating interventions, nutrition consults, standardized application of specialty mattresses, documentation templates and checklists and audit tools (Tayyib et al., 2016; Gaspar et al., 2019; Rivera et al., 2020).

Maintaining adequate nutrition and hydration should be essential to PU management plans. Nutritional assessments should include current and usual weight, history of involuntary weight loss, nutrition intake (protein, calories, fluid), appetite, dental health, chewing, swallowing or feeding problems, medical or surgical history affecting intake or absorption, drug/nutrient interactions, psychosocial factors (mood, finances, cooking ability, culture, preferences) and appropriate laboratory values. Other factors to identify potential nutritional impairments include body mass index (BMI), skin fold thickness, arm circumference, etc.

Common laboratory analyses include hemoglobin A1c (HbA1c), blood urea nitrogen (BUN), total lymphocyte count, serum transferrin, serum albumin, and serum pre-albumin. A total lymphocyte count indicates protein-calorie malnutrition (values below 1,800 mm3 indicate risk); serum transferrin is also a malnutrition indicator (values below 200 mg/dl indicate risk). Serum albumin (20 days half-life indicates chronic disease state, values below 3.5g/dl indicate an increased risk of malnutrition); serum pre-albumin has a two to three-day half-life, which some providers feel may provide a more current reflection of protein stores (values below 15 mg/dl indicates increased nutritional risk). However, several nutritional screening recommendations state that serum proteins such as albumin and serum pre-albumin are "not endorsed for nutritional screening," by the evidence presented in the 2019 NPIAP Pressure Injury Prevention Guidelines (Munoz et al., 2020).

Managing excessive moisture (incontinence, sweat, spilled liquids) on the skin surface of patients at risk for PUs is another critical preventive and management goal (Saindon & Berlowitz, 2020). Managing incontinence includes establishing a bowel and bladder program, cleansing the skin after soiling with pH-balanced cleansers, and using incontinence skin barriers (creams, ointments, etc.) to protect and maintain intact skin. Consider a pouching system or collection device to protect from effluence if fecal incontinence is an issue. Indwelling catheters may be indicated for short-term use with severe incontinence-related dermatitis and difficulty managing urinary incontinence. In addition, limit the use of diapers, but if briefs, diapers, or underpads are used, make sure they are the type that wicks moisture from the skin. In addition, temperature plays an important role concerning moisture. Saindon and Berlowitz (2020) systematically reviewed the PU literature. One of their research study conclusions reported that "higher temperatures at the (skin) surface are transferred to deeper tissues, resulting in greater susceptibility to injury. Too much or too little moisture increases the coefficient of friction, with resulting increases in shear deformation of subcutaneous tissues" (and thus, leading to a potential PU).

Addressing impaired mobility includes patient and caregiver education and establishing a turning/repositioning schedule for patients confined to the bed or a chair. This should include offloading direct pressure over bony prominences and repositioning the patient every two to four hours. Keeping the head of the bed raised at 30 degrees or less except for tube-fed patients (but allowing for elevation for 1 hour after meals) is also deemed important. Avoiding "donut" type seating cushions (rings meant for under coccyx areas) and avoiding pulling the patient across the bed or a chair surface is important for reducing friction and shearing forces. Pressure-redistribution surfaces on bed and chair surfaces for "at-risk" patients should also be utilized (Saindon & Berlowitz, 2020).

Political issues affecting prevention and treatment may include scenarios like the one in Iran, where pressure-reducing equipment is scarce, or situations where a lack of healthcare resources prevents the global implementation of even basic preventative measures. Government-sponsored or subsidized medical care, private insurance, homelessness, drug addiction, war, economic crisis, and limited transportation or food sources are a few huge issues affecting healthcare today. In America, Medicare and Medicaid services come to mind when considering economic, social, and political implications on research findings regarding PU risk. To highlight this point, a roundtable discussion of the International Expert Wound Care Advisory Panel highlights one PU-specific ramification of the Deficit Reduction Act of 2005. The expert panel detailed subsequent changes in the CMS financial reimbursement amounts for long-term and acute care settings such as nursing homes and hospitals. Beginning in October 2008, CMS no longer reimbursed higher rates for patients that develop stage 3 or 4 PUs (full-thickness tissue loss) after admission, representing a potentially substantial economic loss to healthcare facilities. The act was thought to provide additional motivation to acute and long-term care facilities to evaluate and improve their documentation and prevention programs. However, there is a lack of research supporting the reduction in coverage of any improvements in PU prevention or rate reduction. This discussion is significant as it stresses the urgency of a consensus among healthcare providers, particularly the wound care community, in providing effective quality research and evidence-based (and innovative) outcome data related to interventions.

Prevention is paramount!

Address healing impediments, especially nutrition, moisture, temperature, friction, and shear.

Use appropriate mnemonics to help guide wound bed preparation and wound healing approaches.

Any topical wound therapy you select should show expected improvement in two to four weeks. If not, then re-evaluate the wound and evaluate for possible infection (quantitative tissue analysis). Consider measures to address etiologic and systemic factors (nutrition, shear, diabetes, or comorbid disease control). Change to another product if necessary. If the wound worsens or does not improve after doing these things, consider malignancy (biopsy for histopathology) or autoimmune disease(s) as potential contributing factors, such as pyoderma gangrenosum.

As stated before, many changes have occurred in health care over the past 20 years, especially with nursing care delivery, hospital organizational frameworks, quality improvement, financial coverages, not to mention technology (including electronic records), and perhaps the overall face of our present-day patient population. Nevertheless, despite multiple prevention programs implemented nationwide, the incidence and prevalence (and the number of deaths attributed to PUs annually by the CDC) have not changed significantly in many facilities. Researchers need to determine why and develop innovative approaches to solve this dilemma. The effectiveness of prevention and treatment interventions must be determined. Guidelines must be based on current, high-quality scientific evidence, and impediments to implementation must be addressed. There are significant gaps in the scientific literature regarding PU risk assessment in different settings, particularly present-day populations, and how PU risk assessment may impact patient outcomes (Warner-Maron, 2015). New conceptual models of PU development, risk assessment, and effective prevention interventions may need to be developed.

What does the future hold? We already have thermographic scanning for temperature assessment, infrared devices, sub-epidermal moisture detection devices, etc. It will be important to continue to evaluate the efficacy of these devices and technologies, especially regarding future prevention approaches. Assimilating technology such as artificial intelligence (machine learning), automated pressure, temperature, and moisture-sensing devices built into support surfaces, ways to assess the microclimate of skin through clothing or wearable technology may not be too far in our future – and some are already here (Cai et al., 2021; Dweekat et al., 2023; Gefen & Ross, 2020; Saindon & Berlowitz, 2020).

Patient

A 76-year-old African American male, Mr. Smith, presented to the emergency room at 4 pm for a fractured right hip after falling at home. No other complaints were noted. History includes type II diabetes (well-controlled with oral medication and diet), hypertension (no current medication, ran out three months ago), height 5'10", weight 150 lbs (recent weight loss of 25 lbs. over the past three months after wife recently died). Mr. Smith lives alone but has a son who lives two hours away and visits every two weeks. He has been using a walker to ambulate for the past two years since he is "not too steady" on his feet sometimes. Mr. Smith reports he sometimes dribbles urine after urinating but denies any incontinence of urine or stool. The current pain level is eight out of ten. His blood pressure is 170/98. His HbA1c level is 7.2, and his serum glucose is 125.

Risk Assessment

The Braden Scale was used by the admission nurse. Here is how she scored the patient: Sensory Perception: 4 "no impairment"; Moisture: 4 "rarely moist"; Activity: 3 "walks occasionally"; Mobility: 3 "slightly limited"; Nutrition: 3 "Adequate"; Friction & Shear: 3 "No apparent problem" – Total score: 20 (not at risk); Visual skin assessment head-to-toe reveals no redness over any boney prominence. However, a skin tear was noted on the left forearm from a fall at home.

Prevention Intervention Strategies

The patient is placed on a foam mattress (standard for the medical-surgical unit Mr. Smith was admitted to) while awaiting hip surgery. Mr. Smith cannot have anything by mouth (NPO) after midnight, and no nutrition consult has been placed yet. He is on bed rest, and an opioid was ordered for pain relief before surgery. Mr. Smith is using a urinal for voiding during the night. The patient does not want to be turned to the side during the night due to pain.

Initial Clinical Outcomes

Mr. Smith goes to surgery without additional skin assessment, and no one documents any skin warmth at the sacral area or right heel. Perianal moisture is present but not documented by transfer personnel. Mr. Smith is prepped for surgery, and the nurse conducting the perioperative skin assessment notes intact but slightly darker skin over the sacral area. The skin is also warmer to touch over the sacral area than the surrounding skin. The nurse also notes some right hip bruising (diffuse bruising over most of the right lateral hip and thigh – not particularly over trochanter boney prominence), in addition to some right heel bogginess and warmth, and the left forearm skin tear.

Staging

Perioperative nurse documents right hip bruising likely due to fracture injury, a stage 1 sacral PU, and stage 1 right heel PU. The left forearm skin tear is not staged because it is not a PU, and the right hip is not staged due to the nature of bruising consistent with fall injury and fracture.

Management Strategies

Perioperative staff implement specialty gel operating table padding and carefully apply foam padding to the non-operative extremities, head, etc. They also take care to float heels. In recovery, alternating pressure redistribution surface is used, small adjustments to the patient's position are made hourly to relieve pressure to the sacral area, and heels continue to be floated. Vital signs reveal high blood pressure after surgery (200/110) and elevated heart rate (110/min). Labs are unremarkable. The patient is transferred to surgical intensive care for observation. The beds have alternating pressure mattresses and beds with a "turn to assist" capability. When the patient awakes, he reports pain as four out of ten. Post-operative opioids are ordered for pain. The patient remains NPO. The perioperative staff points out all skin findings to the intensive care staff. When the patient was admitted to intensive care, the Braden risk assessment score was: Sensory Perception: 2 "very limited"; Moisture: 2 "often moist"; Activity: 1 "bedfast"; Mobility: 2 "very limited"; Nutrition: 1 "very poor"; Friction & Shear: 1 "problem" – Total score: 9 (severe risk). A nutrition consult and a wound consult by a wound specialist are ordered.

Outcomes

The patient stabilizes within one day and is transferred to a regular medical-surgical floor (on an alternating pressure specialty mattress). The staff now documents the sacral PU as stage 2 superficial open blister but no purple discoloration, and the right heel is now a deep purple color, intact, and still boggy (documented by staff as stage 1). The interdisciplinary team discusses the PU management plan and steps to initiate a care plan to prevent the progression of the existing PU and any new PU. Physical therapy initiates a mobility and strengthening care plan, and the patient starts to ambulate with assistance. A regular turning schedule is implemented at least every two hours, and sips of fluid are offered with a turning schedule. A moisture barrier cream is ordered for the perineum, and the head of the bed is kept at 30 degrees or below (when in bed) except for meals and 30 minutes after meals. Pain that may be present with turning is addressed by medicating Mr. Smith 30 minutes before the turn as needed, and nutrition interventions have been initiated. The social worker and team discuss the best location to discharge the patient, the potential need for home assistance, and the safety assessment of the home environment. Mr. Smith is discharged 12 days after the resolution of the stage 2 sacral PU with no further evolution of the heel PU. Right hip bruising is resolved, and the left forearm skin tear is closed. Mr. Smith's vital signs, including his blood pressure, pulse, and labs, are all unremarkable at discharge.

Strengths of the Case

Perioperative skin assessment was thorough and accurately noted PUs over the sacral area and right heel. The healthcare staff correctly noted right hip bruising due to injury and not a PU (diffuse bruising over most right lateral hip and thigh – not particularly over trochanter boney prominence) and the left forearm skin tear (not a PU). Perioperative staff also implement prevention strategies during surgery (specialty gel operating table padding and careful foam padding to non-operative extremities, head, etc., and take care to float heels). Alternating pressure redistribution surface is appropriately used, with small adjustments to the patient's position regularly made to relieve pressure to the sacral area, and heels continue to be floated. ICU staff correctly score the risk assessment as" 9" (very high risk): 

• Sensory Perception: 2 "very limited" – because the patient is over 65 years old, and some sensory decline is normal in ages over 65 as well as people with diabetes (peripheral neuropathy present in feet), and the patient is on pain medication (decreases sensory perception, and pain may also distract the patient from feeling more minor discomforts).
• Moisture: 2 "often moist" (patient using urinal was noted to frequently spill a little, and perineal moisture was noted even pre-operatively, which could be sweat).
• Activity: 1 "bedfast" (patient was bedfast for several days).
• Mobility: 2 "very limited" (mobility was impaired severely for more than three days).
• Nutrition: 1 "very poor" (NPO for > 24 hours, 25 lb. weight loss prior to admission, and potential appetite changes due to grieving since wife recently died).
• Friction & Shear: 1 "problem" (the nurse felt the score was between a 1 or 2 because the patient was slipping down in bed frequently, needing staff to lift him back up – he was also moist in the perineal area, increasing friction, but selected 1 to capture the most risk possible, to intervene if possible).

Total score: 9 (severe risk) was accurate at admission to intensive care. 

Appropriate interventions based on the level of risk considered for a Braden Scale score of 9 include: Frequent turning; maximal remobilization (early mobility, PT/OT involvement if feasible and patient's condition allows); protect heels (float heels but take care to not cause increased focused pressure to Achilles tendon – if using pillows, use one lengthwise behind each leg at calf and with enough height that heels do not touch bed surface); manage moisture (may include moisture barrier creams, avoid drying the skin, bed pads that wick moisture away from body, address cause of moisture if possible, etc.), manage nutrition and hydration (nutrition consult, increase protein intake, supplement if needed, offer liquids with turn schedules if patient is able to take oral liquids), and friction and shear (maintain head of bed below 30 degrees when not eating if condition is stable, use trapeze when indicated, use lift sheet to move patient, protect elbows and heels during movement if exposed to friction); pressure relieving support surface; turning schedule (low air loss beds or mattress overlays do not substitute for turning schedules); use of foam wedges for 30 degree lateral positioning (if medical condition allows for this); and supplementing turn schedules with small shifts in position more frequently. 

The actions of the staff in the case scenario addressed some of these. Physical therapists initiated a mobility and strengthening plan of care, a regular turning schedule was implemented at least every two hours, and sips of fluid were offered with a turning schedule. A moisture barrier cream was ordered for the perineum, and the head of the bed was kept at 30 degrees or below (when in bed) except for meals and 30 minutes after meals. Pain that may be present with turning was addressed, and nutrition interventions have been initiated. Nutrition and wound consults were placed. An interdisciplinary team and social worker were involved with discharge planning, and a home safety assessment was ordered (to prevent further falls). Self-care needs at home were also evaluated/addressed.

Weaknesses of the Case

The initial Braden score obtained on admission to the hospital facility did not account for the real measure of PU risk or Mr. Smith's age as a risk factor (not accounted for by the Braden tool). The admission assessment documented: 

• Sensory Perception: 4 "no impairment" (this is not accurate)
• Moisture: 4 "rarely moist" (this is not accurate)
• Activity: 3 "walks occasionally"
• Mobility: 3 "slightly limited"
• Nutrition: 3 "Adequate" (this is not accurate)
• Friction & Shear: 3 "No apparent problem" (this is not accurate)
• Total score: 20 (not at risk) was documented on admission.

However, this would have been scored more accurately if these sub-scores were marked in this way: 

• Sensory Perception: 2 (between 2 "Very limited" and 3 "slightly limited," select the lower score) due to the patient's age, diabetes diagnosis, peripheral neuropathy, and pain.
• Moisture: 3 "occasionally moist" (especially at the perineum, since he did dribble urine and didn't realize it).
• Activity: 1 "Bedfast" (the patient had a newly fractured hip and would not be up walking until at least after surgery, and he was in severe pain, which impaired his mobility even in bed – so at the time of the assessment, he should have been considered bedfast).
• Mobility: 2 "very limited" (for the same reasons as activity).
• Nutrition: 1 (between 1 "very poor" and 2 "probably inadequate" for NPO status that would start after midnight and recent significant weight loss).
• Friction & Shear: 1 (between 1 "problem" and 2 "potential problem" due to the patient's severe immobility at the start of hospitalization due to hip fracture and severe pain.

The total admission score should have been between 10 and 12 (both are high-risk scores). Appropriate prevention interventions might have been initiated earlier if this level of risk had been communicated, and the PU he developed may have been avoided.

Additionally, there was room for improvement for the medical-surgical staff related to PU staging of the right heel, which was incorrectly staged as a stage 1 but was a deep purple color, intact, and still boggy (should have been staged as a deep tissue injury). Quicker implementation of powered pressure redistribution support surfaces and better attention to offloading heels pre-operatively may have helped prevent the PUs that developed (AHRQ, 2023; NPIAP, n.d.).

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