LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will have increased your understanding of pressure injury assessment, prevention, and treatment. Specific learning objectives to address potential knowledge gaps include:

• Discuss the impacts of pressure injuries.
• Explain the risk factors for developing pressure injuries.
• Describe the processes for conducting risk assessments and measuring risk associated with pressure injuries.
• Identify actions to help prevent pressure injuries.
• Analyze actions to prevent pressure injuries in special populations.

INTRODUCTION

The skin is the largest organ in the human body—and essential to life and well-being. Human skin serves many vital functions, the most critical of these being to provide a barrier between the external environment and the internal environment of the body. Similar to any other organ in the body, the human skin is susceptible to disease and injury. Wounds involving the skin are a frequent occurrence in all age groups.

A pressure injury is a wound unlike any other in that its cause is not surgery or trauma but death of the skin and underlying tissues from ischemia due to intense and/or prolonged pressure. A pressure injury can also result from a combination of pressure and shear. There are many factors that contribute to the development of a pressure injury and whether or not it will heal, but the biggest factor in all of these is pressure.

Pressure injury is not new, and the terminology to describe it has varied over time:

• Decubitus (18th century)
• Decubitus ulcer (ca. 1950s)
• Bed sore (ca. 1970s)
• Pressure sore (ca. 1980s)
• Pressure ulcer (ca. 1990s)
• Pressure injury (2016–present)
  (PA DOH, 2017)

Defining “Pressure Injury”

Over the years, the definition of a pressure injury has been refined as medical knowledge and understanding of the disease process has advanced, along with improvements in treatment approaches and imaging technology. The National Pressure Injury Advisory Panel (NPIAP, 2016a) definition states:

A pressure injury is localized damage to the skin and 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 as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue.

The localized damage in a pressure injury is the result of compression of soft tissue that interferes with the tissue’s blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure injuries can develop within 24 hours of the initial pressure but may take as long as a week to present themselves. The first tissues to die are nearest the bone, and as the pressure and anoxia continue, the remaining layers of tissue begin to die. The skin is the last to die. The damage can be compared to an iceberg, with a smaller amount of damage visible at the surface and a large amount of damage below the surface.

Pressure injury usually occurs over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors—such as shearing, skin moisture, heat, poor nutrition, comorbidities, and incontinence—also contribute to the tissue breakdown (WOCN, 2022a).

The Impact of Pressure Injuries

The impact of pressure injuries is staggering. Over 2.5 million cases of pressure injuries are reported in the United States on an annual basis, making pressure injuries the second most frequent diagnosis in healthcare billing records in this country. According to Centers for Disease Control and Prevention (CDC) data, pressure injury is the eighth most common cause of death in the United States. Veterans Affairs facilities have pressure injury rates double that of the national average (NPIAP, 2021).

Monitoring skin integrity and taking proactive steps to prevent pressure injury development are a primary responsibility for healthcare providers. Failure to do so can have detrimental consequences for patients, providers, and healthcare facilities, such as:

• First and foremost, these wounds are very painful, causing patients a great deal of suffering.
• Quality of life is affected, as the patient must alter activities to help heal the wound, and they may face long-term hospitalization.
• The anatomical location of the injury may result in a loss of dignity.
• The burden of dealing with a chronic wound can result in stress, anxiety, depression, less autonomy and security, and impaired social functioning.
• A nonhealing injury is at high risk for infection, which can be life threatening.
• Caring for a patient with pressure injury negatively impacts the quality of life for family members and caretakers.
  (WOCN, 2022a)

Pressure injury is a particular problem for bedbound individuals who are hospitalized, in nursing homes, or have spinal cord injuries. Pressure injuries also increase healthcare professionals’ workloads, as additional time and care must be provided to manage and treat patients’ pressure injuries—more dressing changes, more medications, and more documentation.

Litigation may be brought against a hospital and its staff for neglect, malpractice, and elder abuse if a patient develops a pressure injury while in the hospital. Awards can be in the millions of dollars, and the bad publicity that follows will damage the hospital’s reputation, bottom line, and the trust patients have that they can be cared for safely. Cases involving the occurrence of pressure injuries are the primary malpractice claim in this country (NPIAP, 2021).

Pressure injuries are reportable to state and federal agencies. The information is placed in reports accessible to the public. Regardless of the care setting, all providers must account for the number of pressure injuries that were present on admission and on subsequent reassessments, whether they have closed or worsened (CMS, 2022a).

Governmental agencies may levy fines against a hospital for pressure injuries. The Centers for Medicare and Medicaid Services (CMS) no longer pays a hospital for the additional care needed for a patient who develops a hospital-acquired pressure injury, and the hospital must provide the care nonetheless (CMS, 2022b).

Thus, the assessment, prevention, and treatment of pressure injuries are of major importance to healthcare professionals and to the facilities at which they practice. Most facilities have developed pressure injury prevention programs to put these ideas into practice and prevent negative outcomes for both the patient and the facility.