HistoryThe clinical presentation of pressure injuries (pressure ulcers) can be deceiving to the inexperienced observer. Soft tissue, muscle, and skin resist pressure to differing degrees. Generally, muscle is the least resistant and will become necrotic before skin breaks down. Also, pressure is not equally distributed from the bony surface to the overlying skin; it is greatest at the bony prominence, decreasing gradually toward the periphery. A small area of skin breakdown may represent only the tip of the iceberg, with a large cavity and extensive undermining of skin edges beneath. Show In the initial evaluation of a patient with pressure injury, the following important information should be obtained from the history:
Information related to the current pressure injury should also be obtained, particularly with regard to the following:
A complete review of systems, including the presence of fevers, night sweats, rigors, weight loss, weakness, or loss of appetite, should be carried out. Physical ExaminationA thorough physical examination is necessary to evaluate the patient’s overall state of health, comorbidities, nutritional status, and mental status. The patient’s level of comprehension and extent of cooperation dictate the intensity of nursing care that will be required. The presence of contractures or spasticity is important to note and may help identify additional areas at risk for pressure ulceration. After the general physical examination, attention should be turned to the pressure injury. Adequate examination of the wound may necessitate the administration of intravenous (IV) or oral pain medications to ensure patient comfort. Chronic pain may be present among these patients and may be exacerbated by examination ulcer. Many classification schemes have been developed to define the severity of pressure ulcers. [59] For a considerable period, the most widely accepted approach was that of Shea, which was modified and subsequently refined by the National Pressure Ulcer Advisory Panel (NPUAP). [60] In April 2016, the NPUAP (now known as the National Pressure Injury Advisory Panel [NPIAP] since November 2019) announced an updated version of its staging system, along with a change in preferred terminology from pressure ulcer to pressure injury. [1, 2] The NPIAP system consists of four main stages of pressure injury but is not intended to imply that all pressure injuries follow a standard progression from stage 1 to stage 4 or that healing pressure injuries follow a standard regression from stage 4 to stage 1 to a healed wound. Rather, the system is designed to describe the degree of tissue damage observed at a specific time of examination and is meant to facilitate communication among the various disciplines involved in the study and care of patients with these lesions. The categories specified in the current NPIAP staging system are as follows [2] :
Such staging is only a small part of the initial assessment. The injury location, the size of the skin opening (if present), and the presence of any surrounding maceration or induration must be accurately recorded. The presence of multiple pressure injuries prompts a search for interconnecting tracts with overlying skin bridging that may not be readily apparent. The presence or absence of foul odors, wound drainage, and soiling from urinary or fecal incontinence provides information about bacterial contamination and the need for debridement or diversionary procedures. ComplicationsComplications fall into one of two categories: complications of chronic pressure injury (see below) and complications of reconstruction (see Treatment). Complications of chronic injury include the following:
Malignant transformationThe most serious complication of chronic ulceration is malignant transformation or degeneration (see the images below), also referred to as Marjolin ulceration. Although Marjolin initially described malignant transformation of a chronic scar from a burn wound, the term Marjolin ulcer has been commonly applied to the malignant transformation of any chronic wound, including pressure injuries, osteomyelitis, venous stasis ulcers, urethral fistulas, anal fistulas, and other traumatic wounds. [61]  Histologically, this malignant transformation is a well-differentiated squamous cell carcinoma [62] ; however, its behavior is very aggressive in pressure injuries, considerably more so than in burns or osteomyelitis. [63, 61] There is a high likelihood of nodal metastasis at the time of diagnosis. Any long-standing, nonhealing wound should alert the examiner to the need for biopsy. Marjolin ulcers arising from burns or osteomyelitis have been treated with wide local excision, amputation, and lymph node dissection. Because pressure injury carcinoma is substantially more aggressive, more radical treatment (eg, hemicorporectomy and regional node dissection) is required if a cure is to be effected. [63, 61] The actual rate for malignant transformation of a pressure injury is not known but can be assumed to be low, in that only 18 cases have been described in the literature to date. Although apparently rare, pressure ulcer carcinoma is highly lethal: 12 of the 18 known patients died within 2 years. Autonomic dysreflexiaAutonomic dysreflexia is a disordered autonomic response to specific stimuli. It includes sweating and flushing proximal to the injury, nasal congestion, headache, intermittent hypertension, piloerection, and bradytachycardia. Patients with midthoracic spinal cord lesions are most prone to this response. When autonomic dysreflexia is suggested, the patient is first positioned with the head up and monitored for changes in heart rate and blood pressure. Then, the precipitating stimulus must be removed. The most common precipitating cause of autonomic dysreflexia is bladder distention, which is treated by inserting a Foley catheter or irrigating an already placed Foley catheter to remove blockage. Rectal examination to evaluate for fecal impaction should be considered. Nifedipine, hydralazine, or topical nitroglycerin may be administered to stabilize blood pressure. If autonomic dysreflexia does not respond to these measures, spinal anesthesia may be required. OsteomyelitisForemost in the treatment of osteomyelitis is the removal of all nonviable bone, down to bone that bleeds bright red. [64] In the reconstruction of reconstructing pressure injuries associated with osteomyelitis, it is important to use bone that is in the base flaps and has a muscle component. The muscle is placed over this bone after appropriate bone debridement. The flap reconstruction can be performed at the same time as the bone debridement. A 6-week course of IV antibiotics is then administered. PyarthrosisPyarthrosis of the hip joint can occur with communication of ischial or trochanteric ulcers. Often, the femoral head contains osteomyelitis, which necessitates its removal. The Girdlestone arthroplasty procedure has been employed in this situation (ie, hip pyarthrosis), including removal of the femoral head and reconstruction of this space with the vastus lateralis muscle flap (see the image below). [65] SepsisPressure injuries do not cause sepsis. In patients who present with sepsis and pressure injuries, the sepsis is usually caused by a urinary tract infection. These wounds are almost always open to drain and therefore do not constitute debridement emergencies. Only on rare occasions are these injuries entirely occluded by a thick leathery eschar that prevents open drainage. In these cases, debridement is required to facilitate drainage and prevent systemic infection. In general, patients do not die of pressure injuries, but they can die with them. Urethral fistulaPressure injuries can also erode into the urethra (see the images below). Treatment of this complication (ie, urethral fistula) involves urinary diversion. Pressure injury reconstruction can be considered once the fistula has healed.
Author Chief Editor John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract Disclosure: Nothing to disclose. Acknowledgements Kat Kolaski, MD Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation Disclosure: Nothing to disclose. Consuelo T Lorenzo, MD Physiatrist, Department of Physical Medicine and Rehabilitation, Alegent Health Immanuel Rehabilitation Center Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation Disclosure: Nothing to disclose. Joseph A Molnar, MD, PhD, FACS Director, Wound Care Center, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Peripheral Nerve Society, Undersea and Hyperbaric Medical Society, and Wound Healing Society Disclosure: Abbott Laboratories Honoraria Speaking and teaching; Clincal Cell Culture Grant/research funds Co-investigator; KCI, Inc Wake Forest University receives royalties Other Michael Neumeister, MD, FRCSC, FRCSC, FACS Chairman, Professor, Division of Plastic Surgery, Director of Hand/Microsurgery Fellowship Program, Chief of Microsurgery and Research, Institute of Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine Michael Neumeister, MD, FRCSC, FRCSC, FACS is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Association of Academic Chairmen of Plastic Surgery, CanadianSocietyofPlastic Surgeons, Illinois State Medical Society, Illinois State Medical Society, Ontario Medical Association, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, and Society of University Surgeons Disclosure: Nothing to disclose. Adrian Popescu, MD Research Fellow, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine Disclosure: Nothing to disclose. Patrick J Potter, MD, FRCP(C) Associate Professor, Department of Physical Medicine and Rehabilitation, University of Western Ontario School of Medicine; Consulting Staff, Department of Physical Medicine and Rehabilitation, St Joseph's Health Care Centre Patrick J Potter, MD, FRCP(C) is a member of the following medical societies: American Paraplegia Society, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada Disclosure: Nothing to disclose. Don R Revis Jr, MD Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine Don R Revis Jr, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons Disclosure: Nothing to disclose. Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society Disclosure: Nothing to disclose. Wayne Karl Stadelmann, MD Stadelmann Plastic Surgery, PC Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Bradon J Wilhelmi, MD Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Association of Clinical Anatomists, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons,Association for Surgical Education, Plastic Surgery Research Council, and Wound Healing Society Disclosure: Nothing to disclose. Acknowledgments The authors and editors of Medscape Reference gratefully acknowledge the contributions of Steve Jenkins in the Department of Physical Medicine and Rehabilitation at the University of Kentucky for his significant editorial assistance in preparing this article. Dr Richard Salcido acknowledges that his studies cited in this article are supported by the National Heart, Lung and Blood Institute, the National Institutes of Health grant P01HL36552-07, the National Center for Medical Rehabilitation Research grant R01HD31426-01, the Paralyzed How do you assess for pressure injury?Check for areas of localised heat, skin breakdown, oedema, areas of redness that do not blanch and induration of the wound. Particular attention should be paid to areas of bony prominence, which are at an increased risk for pressure injury due to pressure, friction and shearing forces.
What are at least 5 risk factors for pressure ulcer development?Risk factors. Immobility. This might be due to poor health, spinal cord injury and other causes.. Incontinence. Skin becomes more vulnerable with extended exposure to urine and stool.. Lack of sensory perception. ... . Poor nutrition and hydration. ... . Medical conditions affecting blood flow.. How do you identify and assess pressure areas?Test your skin with the blanching test: Press on the red, pink or darkened area with your finger. The area should go white; remove the pressure and the area should return to red, pink or darkened color within a few seconds, indicating good blood flow.
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What are five 5 main criteria that should be included when examining and assessing a pressure injury?
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