Pressure Injuries

At first, the skin may appear reddened. Or the skin may look purple or dark red. In darker skin, the color may differ from that of nearby skin. The injury may be tender and warm to the touch. It may break open or form an ulcer where fat, bone, or muscle may be visible.

Pressure injuries are injuries to the skin and underlying tissue. They can range from mild reddening of the skin to severe tissue damage—and sometimes infection—that extends into muscle and bone. Pressure injuries are described in the following stages.

• Stage 1 pressure injuries are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 injury can feel either firmer or softer than the area around it.
• Stage 2 pressure injuries are open wounds. The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The wound expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
• Stage 3 pressure injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone.
• Stage 4 pressure injuries extend to muscle, tendon, or bone.
• Unstageable pressure injuries are when the stage is not clear. In these cases, the base of the wound is covered by a layer of dead tissue that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the wound to determine the stage.
• Deep tissue pressure injuries are when there isn't an open wound, but the tissues beneath the surface have been damaged. The area of skin may look purple or dark red, or there may be a blood-filled blister. If you or your doctor suspect a pressure injury, the area is treated as though a pressure injury has formed.

Serious complications, such as infection of the bone (osteomyelitis) or blood (sepsis), can occur if pressure injuries progress.

Pressure injuries are caused by constant pressure on the skin and tissues.

Other things that can make pressure injuries more likely include:

• Sliding down in a bed or chair (shear force).
• Being pulled across bed sheets or other surfaces (friction).
• Not getting enough nutrition to keep your body working well (malnutrition).
• Not being able to get out of bed or walk around (immobility).
• Having a disease that affects how well blood circulates in your body, such as diabetes or peripheral arterial disease.
• Excess moisture, such as from sweat, urine, or feces. Skin that is often wet is more likely to break down and form pressure injuries.

Relieving and spreading out pressure is the most important part of both preventing and treating pressure injuries. Putting pressure on one spot for long periods of time damages the skin and underlying tissues. Pressure can be relieved and spread in several ways. Often a combination of these is best.

• Change position often.
  • In a bed, change position every 2 hours. Learn how to move yourself so that you avoid folding and twisting your skin.
  • In a wheelchair or other type of chair, shift your weight every 15 minutes.
  • Try not to slide or slump across sheets in a chair or bed. Recliner chairs are likely to allow slipping, so don't sleep in a recliner. Try to keep the head of a bed, a recliner chair, or a reclining wheelchair raised no more than 30 degrees.
• Take good care of your skin.
  • Bathe as often as needed to be clean and comfortable. Use gentle soap, and use warm (not hot) water. Be careful not to scrub the skin too hard.
  • If you have problems with bowel or bladder control, clean your skin right away if it gets soiled or wet. Use a protective barrier cream, lotion, or ointment to protect your skin from wetness. Use pads or briefs that absorb moisture and pull it away from your skin.
  • If you have dry skin, use moisturizing cream or lotion to keep your skin from drying out and cracking.
  • Check your skin every day for signs of pressure injuries. Pay special attention to bony areas such as the hips, elbows, knees, and heels. Also watch for pressure from sources such as:
    • Body parts or skin folds, especially if you're overweight.
    • Chair arms, parts of wheelchairs, braces, or other places where you rest your elbows or other body parts.
    • Medical equipment such as oxygen masks or oxygen tubing.
• Make healthy choices.
  • Eat healthy foods with enough protein, and get plenty of fluids (unless your doctor has told you to limit your fluid intake). That can help damaged skin heal and help new skin grow.
  • If you smoke, quit or cut back as much as you can. Talk to your doctor if you need help quitting. Smoking dries the skin and reduces blood supply to the skin.
• Talk to your doctor about pressure-relieving cushions and pads.
  • Use special support surfaces. There are mattresses, bed covers, and chair cushions designed to help reduce and spread pressure.
  • Ask your doctor which cushions and pads might help you. Some products, such as doughnut-type devices, may actually cause pressure injuries or make them worse.

If you or someone you care for is not able to move much, it's important to prevent pressure injuries and to check the skin every day. If you think that a pressure injury is forming, take steps to treat it. Talk to your doctor or nurse about what more you can do.

Treatment focuses on preventing a pressure injury from getting worse and on making the skin healthy again. It may include:

• Taking pressure off the area, changing positions often, and spreading body weight evenly with special mattresses, pads, or other support.
• Keeping the wound clean and covered with a bandage. The doctor will tell you how to care for your wound. You may need to keep the wound a little moist and not let it dry out between bandage changes.
• Eating a healthy diet with enough protein.
• Having debridement. This is when the doctor removes dead tissue from the wound to promote healing.
• Having surgery. Severe pressure injuries may be treated with surgery. A tissue flap or skin graft may be needed.

Negative-pressure wound therapy, also called vacuum-assisted closure, may be used to help with healing.

Researchers continue to study these and other treatments for wounds, including electrical stimulation, hyperbaric oxygen therapy, platelet-derived growth factor, and ultrasound therapy.