Prevention and management of pressure injuries in clinical settings

Sudhamani1, Gowtham2

1Nursing Supervisor, Kauvery Hospital, Marathahalli

2Nursing educator, Kauvery Hospital, Marathahalli

Abstract

Pressure injuries, formerly known as pressure ulcers or bedsores, are a significant cause of patient morbidity, especially among immobilized and elderly populations. These injuries result from prolonged pressure on the skin and underlying tissues, leading to ischemia and eventual tissue necrosis. This paper highlights the anatomy of the skin, physiological basis of pressure injuries, risk factors, assessment tools like the Braden and PUSH scales, and nursing interventions. This report presents a comprehensive review of these aspects, emphasizing the crucial role of nurses in prevention, assessment, and treatment.

Introduction

Pressure injuries are localized damage to the skin and underlying tissues, primarily caused by prolonged pressure or pressure in combination with shear. These injuries often occur over bony prominences and are most common in hospitalized or bed-bound patients. Prevention and early detection are critical to reducing healthcare costs and improving patient outcomes.

Anatomy and Physiology of the Skin

The skin comprises three layers, each playing a role in protection and regulation:

  • Epidermis: The outermost layer; prevents water loss and shields against external injuries.
  • Dermis: Contains blood vessels, nerves, and hair follicles; essential for sensory and thermoregulatory functions.
  • Hypodermis (Subcutaneous Tissue): Connects the skin to muscles and bones and provides insulation and cushioning.

Definition and Pathophysiology of Pressure Injuries

A pressure ulcer develops when prolonged pressure on the skin impedes blood flow, leading to:

  • Tissue ischemia
  • Nutritional and oxygen deprivation
  • Cellular death and necrosis

Epidemiology

  • Affects approximately 1–3 million individuals annually in the U.S.
  • Estimated annual treatment cost: $5 billion
  • Pressure ulcers contribute significantly to patient mortality and morbidity.

Common settings

  • Hospitals (60%)
  • Nursing Homes (18%)
  • Home Care (18%)

High-risk populations include postoperative hip fracture patients and long-term care residents.

Common Pressure Points

  • Sacrum
  • Heels
  • Hips
  • Elbows
  • Shoulders
  • Occiput

Preventive Action: Repositioning immobile patients every two hours can significantly reduce pressure ulcer incidence.

“Four Enemies” of Skin (Friends of Pressure Ulcer)

  • Pressure
  • Shear
  • Friction
  • Moisture

These elements contribute to skin breakdown and must be mitigated through strategic nursing interventions.

Risk Factors for Pressure Injuries

  • Immobility
  • Malnutrition
  • Incontinence (fecal and urinary)
  • Altered consciousness
  • Neurological disorders
  • Spinal cord or traumatic brain injuries
  • Aging skin (reduced blood flow, decreased sensation)
  • Chronic systemic diseases (e.g., diabetes, vascular disorders)

Assessment Tools

Braden Scale

  • Evaluates risk based on six components:
  • Sensory Perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction & Shear

Each category is scored, and the total score determines the patient’s risk level. Lower scores indicate higher risk.

PUSH Tool (Pressure Ulcer Scale for Healing)

  • Monitors ulcer healing over time based on:
  • Wound size
  • Exudate amount
  • Tissue type

This scale assists in evaluating treatment effectiveness and guides care planning and Prevention Strategies. “Prevention is better than cure” is especially applicable in the case of pressure injuries.

Key approaches include:

  • Frequent position changes
  • Daily skin inspection
  • Use of pressure-relieving devices (air mattresses, foam cushions)
  • Controlling moisture and incontinence
  • Ensuring adequate nutrition and hydration
  • Patient and caregiver education to recognize early signs and adopt preventive care

Treatment Modalities

Treatment is based on the stage and severity of the injury:

  • Conservative wound care: Dressings, debridement, infection control
  • Surgical interventions: Tissue flaps or plastic surgery in advanced stages
  • Advanced therapies (under investigation):
    • Hyperbaric oxygen therapy
    • Human growth factor applications

Role of Nurses in Pressure Injury Management

Nurses are central to both prevention and treatment. Key responsibilities include;

  • Comprehensive assessment of skin and risk factors
  • Regular monitoring and documentation
  • Implementing turning and repositioning schedules
  • Maintaining hygiene and skin moisture balance
  • Nutritional assessment and intervention
  • Educating patients and caregivers
  • Minimizing shear and friction forces
  • Collaborating with wound care teams and physicians for advanced cases

Conclusion

Pressure injuries are preventable yet prevalent complications in immobile and critically ill patients. Effective prevention, timely assessment using tools like the Braden Scale and PUSH tool, and skilled nursing care can dramatically improve patient outcomes. The critical care nurses play in maintaining skin integrity and delivering holistic, patient-centered care.

Kauvery Hospital