Most PI’s are avoidable and can be prevented. Risk assessment tools are designed to alert health care staff that a person is at risk for sustaining PI. There are a number of risk assessment tools that are validated for use including the Braden Scale for Predicting Pressure Sore Risk, the Norton Scale, or the Waterlow scale (Fletcher, 2017). These tools should be completed upon admission to a healthcare facility/agency within the first 24 hours of admission, and at regular intervals thereafter (RNAO, 2016). Risk assessment tools are an effective way of determining patient susceptibility to PI development and should always be used in conjunction with clinical judgement.
Treatment plans are an essential part of preventing PI’s. After completing the risk assessment, it is beneficial to utilize the risk assessment tool to develop your plan. For example, if a person scores low in the mobility and nutrition categories (as in the Braden Scale for Predicting Pressure Sore), you will focus on implementing interventions to reduce these risk factors.
Support Surfaces and Equipment
Active and reactive support surfaces have been shown to reduce the incidence of PI’s by up to 60% (McNichol, 2020). Active support surfaces are a powered surface with the capability to change load distribution properties, regardless of applied load. (Norton et al., 2011) Common examples are alternating pressure air mattresses. Reactive support surfaces are ‘‘a powered or non-powered support surface with the capability to change load distribution properties only in response to applied load. (Norton et al.,2011) Common examples are gel mattress or static low-air loss mattress. Support surfaces should be considered anytime a person is shown to be at risk of a PI. Choosing the right support surface is simplified by using a surface selection algorithm (Figure A, Norton et al). Clinicians should check all support surfaces to ensure they are working properly, prior to the person sitting or lying on them.
Support surfaces are an effective way to redistribute pressure over bony prominences but do not replace appropriate turning and repositioning. High risk individuals will require more frequent turning and repositioning than a person who is determined to be at moderate risk. Individuals who require assistance for transferring should be engaging in safe transfer techniques. These may include mechanical lifts, sliding boards, transfer poles and other transferring aids. Repositioning devices such as slider sheets are also beneficial in reducing friction and shear while moving a person in bed.
Table 1 Validation & Risk Assessment Score or Pressure Ulcer Description
|Ability to change position in bed (ie. bed mobility||Validate Risk Assessment Score or Pressure Ulcer Description|
Redness present that fades quickly when pressure removed
1 pressure ulcer (excluding the heels) where the client can be positioned off the ulcer
1 pressure ulcer (excluding the heels) and redness over another area
|Very High Risk
Multiple Pressure ulcers (excluding the heels) or the client cannot be positioned off of an ulcerated area
|Total assist to change position in bed||Reactive
eg. air/gel/foam overlay)
|Reactive Support Surface
(eg. air/gel/foam overlay)
|Active Support Surface
Multi-Zoned Surface (eg. alternating pressure mattress, rotational surface) or a powered reactive support surface (eg. low air loss)
|Active Support Surface
Multi-Zoned Surface (eg. Alternating pressure mattress. rotational surface)
|Moderate assistance with bed mobility||Reactive Support Surface (non-powered
eg. air/gel/foam overlay)
|Reactive Support Surface (eg. foam overlay with air section insert in the area of the wound)||Reactive Support Surface (non-powered eg. foam overlay with air section insert in the area of the wound)||Active Support Surface
Multi-Zoned Surface (eg. alternating pressure mattress. rotational surface)
|Client independent with or without a device with bed positioning (light assist may be required||Reactive Support Surface (High-density foam mattress)||Reactive Support Surface (eg. foam overlay with air section insert)||Reactive Support Surface (non-powered eg. air/gel/foam overlay)||Active Support Surface (if the controls can be placed within the client’s reach)|
1. With a validated risk assessment tool, determine the patient’s level of risk or grade the patients with ulcers based on clinical descriptors.
2. Assess the level of mobility in bed and follow the column-and-row intersection to determine the appropriate reactive or active support system.
3. For more information on the reactive surfaces, see Figure 2, and for more information on active surfaces see Figure 3.
Treat the Cause
Assessing how pressure injuries occur is important in prevention and to assist in healing of a PI. Even the most expensive dressing will fail if the precipitating cause is not identified and removed or modified. PIs occur as a result of pressure or pressure in combination with shear. The risk of injury is influenced by the magnitude and duration of tissue loading but also by susceptibility factors in the individual. (EPIAP, NPIAP, PPPIA, 2019)
In treating a PI, determine the source of the mechanical load while considering:
- direct pressure – the force perpendicular to the body
- shear – used to describe the force parallel to the skin surface which can deform deep tissue structures (e.g., skin moves in 1 direction and the bony skeleton moves in the opposite direction) and
- friction – a force in the interface between the body and a medical device which can be static (fixed) or dynamic (when there is movement between the surfaces) (EPIAP, NPIAP, PPPIA, 2019)
Examining your patient while being aware of the mechanical loads being placed on superficial and deep tissues in all positions of sitting, standing, lying is important to ascertain the cause of PI. The absolute pressure as well as the duration of the applied pressure is important to take into consideration. However, even low pressure can cause tissue damage if other susceptibility factors are present includingsuch as poor nutrition, moisture and high pressures can lead to tissue damage in a very short time. (Gefen & Levine, 2018; Lustig et al., 2018).
Susceptibility factors in the individual include advancing age, poor general medical condition, medications and nutritional levels and can influence the development and repair mechanisms of the skin and deeper structures. Mobility and sensory perception of the individual also effects PI risks. The extent of factors to be addressed makes it important to work as a team in both the prevention and management of PI.
It is important to work with prescribing practitioners to identify any conditions or medications that might need to be assessed. Common examples of this include:
- Reviewing and possibly adjusting the many medications for inflammatory conditions including arthritis
- Optimal management of diabetes with acceptable glycemic control will assist in wound healing
- Assessment of oxygen saturation, peripheral pulses and capillary refill are important aspects to note and discuss with the team
- Involvement of rehabilitation professionals, especially the inclusion of occupational and physical therapists to assess mobility, all transfers and all surfaces used by the patient. This will contribute to wound healing as well as prevention
- Patients benefit from a review of how they might be altering their position to perform pressure redistribution maneuvers on a regular basis.
Some unique aspects of prevention and treatment of the cause of a PI arise particularly in special populations such as critically ill individuals, individuals with spinal cord injury, obesity, those receiving palliative care and in supported living environments.
Moisture from incontinence or perspiration can affect the barrier function of the epidermis and increase the potential for pressure injury. Incontinence is frequently associated with impaired mobility which contributes to the risk for PI development. The coefficient of friction is greater over moist skin contributing to skin breakdown. (Klassen et al., 2016). A whole team approach to managing moisture from incontinence is advised. Methods to schedule bowel care routines to prevent fecal incontinence (SCIRE, Spinal Cord Injury Research Evidence SCIREproject.com) include careful use of oral laxatives and facilitating bowel evacuation at scheduled times with routine timing, taking advantage of the gastrocolic reflex after meals as well as judicious use of rectal methods of stimulating evacuation with suppositories/enema/transanal irrigation etc., can promote better fecal continence. In some cases to facilitate healing of a PI, diversion with colostomy is required. Methods to manage urinary incontinence can include medications to improve the capacity for the bladder to retain urine, regular timed toileting regimens, careful management of fluid intake and if needed, diversion methods. These strategies may include condom drainage, indwelling urethral or suprapubic catheters or other more invasive surgical methods. As an adjunct to these measures, moisture absorbing pads or incontinence briefs in conjunction with skin protectants are used to reduce moisture at the skin surface. (Bernatchez et al., 2015) Management of moisture from perspiration includes assessment and management of the environment and body temperature. Occasionally, more active management can include medications or other treatments to reduce perspiration if severe.
Malnutrition contributes to an increased risk of wounds but also can delay wound healing (Agarwal et.al., 2010; Posthauer et al., 2015) In a Canadian prospective study, adult malnutrition was identified in 45% of patients admitted to hospitals over a 3-year period. Malnutrition in general is a reduced nutrition intake relative to needs (Mackay, 2019; Allard et al., 2016). The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition has adopted a standard diagnosis which includes weight loss as one of six criteria but there is growing recognition that malnutrition occurs even in overweight individuals. (White, 2012; Ness, 2018). The Canadian Malnutrition Screening Tool is recommended to be used to screen for early identification of those at risk for malnutrition. A positive screen indicates the need for a more detailed nutrition assessment by a nutritional specialist.
Root causes of malnutrition require input and possibly intervention from the patient, family and care team. Specific recommendations may be made regarding nutritional intake requirements of protein, calories, fluid and micronutrients. The contribution of malnutrition to delayed healing of PI cannot be overstated. Individuals with significant PI often enter a spiral of inflammation and malaise which further reduces appetite and worsens their ability to heal. Engaging the patient in understanding the specific nutrition requirements to support PI healing can interrupt this cycle.
Most of the risk assessment tools for PI include assessment of sensory perception. ( example Braden, Spina Cord Injury Pressure Ulcer Scale) The 2019 NPIAP guidelines recommend assessing sensory perception particularly with diagnoses associated with sensory impairment such as diabetes, spinal cord injury, peripheral arterial disease. Other patient conditions include altered consciousness like coma or patients under anesthesia. Reduced sensory perception may alter the patient’s ability to respond to pressures placed on skin and deeper tissues. In addition, sensory perception needs to be taken into account during treatment planning and dressing changes.
There are situations, such as in patients with spinal cord injury, where the patient may not feel in the area of the wound but stimulation of dressing changes, bedside debridement etc. can cause mass reactions resulting in potential harmful elevations in blood pressure. Adequate pre-procedural analgesia is of critical importance in all patients. (Allen and Leslie 2019, Mhatre et al 2013)
Activity and mobility limitations are associated with the development of PI. Patients unable to independently mobilize in bed or chair are at risk of PIs on dependent areas of the body and generally over bony prominences. In addition, these high-risk areas for PIs can be put at further risk by contractures or limited range of motion. This limits the ability to position the patient where pressure can be distributed over the largest surface possible.
Friction and shear forces during transfers or other movement further increases the risk of injury to superficial or deep tissues respectively and influences the development or delayed healing of PI. An interprofessional team approach is required to investigate and optimize positioning, seating, transfers, management of contractures, tremors and spasticity in order to prevent and manage PIs.