Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 4-04: Management of Common Geriatric Problems + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Examine at-risk patients on admission to hospital and daily thereafter Pressure injury should be described by one of six stages: Stage 1: Non-blanchable erythema of intact skin Stage 2: Partial-thickness skin loss with exposed dermis Stage 3: Full-thickness skin loss Stage 4: Full-thickness skin and tissue loss Unstageable: Obscured full-thickness skin and tissue loss Deep tissue: Persistent non-blanchable deep red, maroon or purple discoloration +++ General Considerations ++ Incidence rates range from 12% to 16% of hospitalized patients and vary according to patient characteristics The primary risk factor for pressure injury is immobility Other contributing risk factors include Reduced sensory perception Moisture (urinary and fecal incontinence) Poor nutritional status Friction and shear forces + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ The skin overlying the sacrum and hips is most commonly involved, but bedsores may also be seen over the occiput, ears, elbows, heels, and ankles +++ Differential Diagnosis ++ Herpes simplex virus In immunocompromised patients, particularly if there is a scalloped border, representing the erosions of herpetic vesicles Skin cancer In the perianal area, a nonhealing injury may be cancer Pyoderma gangrenosum Rapidly expanding injury associated with inflammatory bowel disease Ecthyma gangrenosum Ulcerating lesion, commonly due to Pseudomonas, observed in neutropenic patients + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Based on clinical appearance Suspect an alternative diagnosis if injuries not healing properly + Treatment Download Section PDF Listen +++ +++ Medications ++ See Table 4–3 The type of dressing that is recommended depends on the location and depth of the injury, whether necrotic tissue or dead space is present, and amount of exudate ++Table Graphic Jump LocationTable 4–3.Treatment of pressure injury.View Table||Download (.pdf) Table 4–3. Treatment of pressure injury. Injury Type Dressing Type and Considerations Stage 1 and deep tissue injury Polyurethane film Hydrocolloid wafer Semipermeable foam dressing Stage 2 Hydrocolloid wafers Semipermeable foam dressing Polyurethane film Stages 3 and 4 For highly exudative wounds, use highly absorptive dressing or packing, such as calcium alginate Wounds with necrotic debris must be debrided Debridement can be autolytic, enzymatic, or surgical Shallow, clean wounds can be dressed with hydrocolloid wafers, semipermeable foam, or polyurethane film Deep wounds can be packed with gauze; if the wound is deep and highly exudative, an absorptive packing should be used Heel injury Do not remove eschar on heel ulcers because it can help promote healing (eschar in other locations should be debrided) Unstageable Debride before deciding on further therapy Deep tissue injury Avoid pressure to the area +++ Surgery ++ Established lesions require surgery for débridement, cleansing, and dressing +++ Therapeutic Procedures ++ Treatment is aimed toward removing necrotic debris and maintaining a moist wound bed that will promote healing and formation of granulation tissue Efforts to promote mobility Repositioning of immobile patients every 2–3 h Air fluid beds and low air loss beds may be useful + Outcome Download Section PDF Listen +++ +++ Complications ++ Infection Pain Cellulitis Osteomyelitis +++ Prevention ++ Strategies that have been shown to reduce pressure injuries Using specialized support surfaces (including mattresses, beds, and cushions) Repositioning the patient Optimizing nutritional status Moisturizing sacral skin For moderate- to high-risk patients, mattresses or overlays that reduce tissue pressure below a standard mattress appear to be superior to standard mattresses +++ When to Refer ++ Injuries that are large or nonhealing should be referred to a plastic or general surgeon or dermatologist for biopsy, debridement, and possible skin grafting +++ When to Admit ++ If the primary residence is unable to provide adequate wound care or pressure reduction If the wound is infected If complex or surgical wound care is required + References Download Section PDF Listen +++ + +Beers EH. Palliative wound care: less is more. Surg Clin North Am. 2019 Oct;99(5):899–919. [PubMed: 31446917] + +Qaseem A et al. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359–69. [PubMed: 25732278] + +Qaseem A et al. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370–9. [PubMed: 25732279] + +Ricci JA et al. Evidence-based medicine: the evaluation and treatment of pressure injuries. Plast Reconstr Surg. 2017 Jan;139(1):275–86. [PubMed: 28027261] + +Westby MJ et al. Dressings and topical agents for treating pressure ulcers. Cochrane Database Syst Rev. 2017 Jun 22;6:CD011947. [PubMed: 28639707]