Pressure injuries toolbox
The pressure injuries toolbox
Management of a skin problem can be challenging because many factors play a role. A single strategy, for example, applying a wound dressing, may not be as effective when used in combination with other strategies. Your specialist nurse or doctor may need to try a combination of treatments and this may take some time.
Think about using the pressure injuries toolbox to treat your pressure injury. The toolbox is made up of 8 strategies as seen in the picture below.
Important Note
It is unlikely that using just one strategy will fix a pressure injury. Consult a specialist nurse or doctor to find the best combination of strategies to use.
The eight strategies
A proper assessment of a pressure injury considers all the possible factors that can impact healing and risk of recurrence.
These factors include:
- Spinal cord injury-specific factors
- Classification of stages of pressure injury
- Diet and nutrition
- Mechanical factors
- Pre-existing medical conditions
- Psychological and lifestyle factors.
- It is recommended to assess and address all of the above factors while monitoring them regularly to maximise pressure injury healing.
Spinal cord injury-specific factors
A variety of characteristics associated with a spinal cord injury affect your risk of getting a pressure injury and the time for healing. Factors include level and extent of injury, ageing, spasms, and bladder and bowel incontinence.
Remember that the greatest pressure is always on the deep tissues and overlying bony prominences.
Locations where pressure injuries commonly develop are shown in the picture below:
Do you know?
90% of pressure injuries are preventable.
Classification of stage of pressure injury
Pressure injury can be divided into 6 types. Duration of healing is directly related to the relevant pressure injury stage and applying the appropriate treatment. The 6 stages are:
Stage 1
Intact skin with a localised area of non-blanching redness with pressing, usually over a bony prominence. If treated early, stage I pressure injury can heal in about 3 days.
Stage 2
Partial thickness loss of dermis presenting as a shallow open wound with a red-pink wound base. Healing from this stage can last anywhere from 3 days to 3 weeks.
Stage 3
Wound extending through epidermis and dermis into the fatty subcutaneous layer. Healing usually needs at least 1 to 4 months.
Stage 4
Full thickness tissue loss extending into underlying tissues, such as muscle and possibly bone. Healing can take anywhere from 3 months to 2 years.
Deep tissue injury
Purple or maroon localised area, an area of discoloured intact skin, or a blood-filled blister.
Unstageable
Full thickness tissue loss in which the base of the pressure injury is covered by unhealthy skin.
Image courtesy of The National Pressure Ulcer Advisory Panel 2016
Diet and nutrition
Unplanned weight loss, nutritional deficiency and insufficient dietary intake are key risk factors for development of a pressure injury and impaired wound healing. Assessment of nutritional status using suitable tools and techniques will help to guide interventions for improving nutritional status and promoting pressure injury healing. Seeking advice from a qualified dietitian is recommended.
For more detailed information, refer to the Diet and nutrition section.
Mechanical factors
Various mechanical factors can influence healing of a pressure injury:
- Impaired mobility
- Altered sensory perception
- Reduced tissue tolerance due to:
- Moisture
- Friction
- Shear.
Strategies:
- Avoid weight bearing on the pressure injury area
- Minimise weight bearing over bony prominences by:
- Leaning forward or to side in your wheelchair for 2 minutes for regular pressure relief
- Frequently changing position while in bed.
Pre-existing medical conditions
If your pressure injury is not healing after 4 weeks (it should be improving by at least 25% per month) or getting worse despite intervention, ask your GP to screen for common conditions, such as anaemia, infection, diabetes and nutritional deficiency, which are known to delay healing. Ensure that you receive appropriate treatment if any of these medical conditions are present.
The presence of infection in the pressure injury can be assessed using the below guide:
If 3 or more of the following signs are present, this means you have a high amount of bacteria in a superficial wound
- Your pressure injury is not healing
- Increasing ooze (exudate) from your pressure injury
- Red, friable tissue that tears and bleeds more easily
- Appearance of unhealthy tissue with debris or dead cells
- Your pressure injury is smelly.
If 3 or more of the following signs are present, this means you have a high amount of bacteria in a deep wound and surrounding skin
- Your pressure injury has increased in size
- You have a fever
- Exposed bone can be seen at the base of your pressure injury
- You have developed a new pressure injury in the surrounding area
- Redness and swelling (cellulitis) in the surrounding skin
- Increasing ooze (exudate) from your pressure injury
- Your pressure injury is smelly.
Increasing clinical problems
Contamination (being made impure)
Colonisation (establishing in an area)
Vigilance required
Local infection
Spreading infection
Systemic infection (widespread infection)
Vigilance required
Medical treatment required
Source: Wound Care Made Incredibly Easy! 2nd ed., Lippincott Williams & Wilkins, 2007.
Ask your GP to perform the following tests to rule out certain health conditions:
Check for level of haemoglobin (cells carrying oxygen to tissues) and the number of white blood cells (that fight infection).
Check for level of haemoglobin (cells carrying oxygen to tissues) and the number of white blood cells (that fight infection).
C-reactive protein and ESR which are raised with infection.
Check for levels of ferritin, serum iron, percentage saturation, and total iron binding capacity which aids healing.
Check for fasting or random blood glucose, as well as markers of adequate nutrition, including protein, prealbumin and albumin levels.
What does research tell you?
It is recommended to use antimicrobial dressings if signs of infection are present.
Psychosocial and lifestyle factors
Psychosocial and lifestyle factors also contribute significantly to skin breakdown and impact on wound healing. Consider the following factors:
- Limited social support or living alone
- Inadequate personal care and/or domestic assistance
- Caregiver fatigue
- Financial concerns including access to quality equipment, repairs and provision of services
- Unsustainable work or family commitments
- Signs of mental health concerns, such as depressed mood, social withdrawal, excess use of drugs or alcohol, or worsening of a pre-existing mental health condition
- Level of motivation
- Lifestyle priorities, competing interests, roles and responsibilities (trade-off between pressure management requirements and living life)
- Reduced ability to self-manage/direct care, problem solve and troubleshoot
- Smoking.
An effective way of treating a pressure injury is to have a comprehensive treatment plan developed with the support of an interdisciplinary team that may include doctors, community nurses, wound nurses, therapists, social workers, psychologists, engineers and dietitians.
The plan should address the cause of the pressure injury, other contributing factors, methods for relieving pressure, specific wound care, adjunctive therapies to support healing as necessary, surgery for complex or deep pressure injuries (stage 3 and 4, if indicated), management of complications, and educational and nutritional interventions.
Interdisciplinary team members for pressure injury management
What does research tell you?
Expert opinion recommends a comprehensive assessment by an interdisciplinary team to identify pressure injury risk factors. This assessment includes level and completeness of your spinal cord injury, associated health conditions, level of functioning and mobility, nutritional status, continence, psychological and social factors, care and equipment.
Good wound care is important and includes:
Cleansing
Cleanse pressure injuries at each dressing change with a generous volume of sterile solution, e.g. saline water.
Consider adding an antiseptic agent if there are signs of infections, e.g. Betadine Solution.
Dressings
The selected dressing should:
- Provide an optimal level of moisture to the wound base of a stage 2 or 3 pressure injury.
- Meet your needs based on the location of the pressure injury or injuries and can be modified depending on your goals and/or change in wound status.
Avoid daily dressing changes if possible, by using a dressing type (absorbent dressing) that manages fluid coming out from the wound bed (also known as exudate) and odour as well as remains in place for as long as possible.
In some instances, wound care may also include wound debridement
Debridement is the removal of dead (necrotic) or infected skin tissue to help a wound heal.
Ensure only a qualified doctor or a nurse debrides devitalised (dead) tissue from a pressure injury, using a method appropriate to the wound status.
Should you need to use any of these strategies you are advised to discuss this with your community nurse or general practitioner before applying.
Deciding on what type of wound care dressing is right for your situation
Selecting the right dressing will depend on:
- The size of your wound
- The amount of moisture in the wound
- The level of infection
- The condition of the surrounding skin.
Dressing moisture scale
Pressure injury is too moist
Absorb moisture by:
- Promoting debridement and cleaning the dead tissue from the wound, using an alginate dressing.
- Using an absorptive dressing that contains multiple layers of highly absorbent materials suitable for draining wounds.
- Using a hydrocolloid dressing that is adhesive, mouldable, impermeable to oxygen and water, and promotes debridement.
- Filling a deep wound with wound fillers to promote healing.
- Using foams to provide thermal insulation and create a moist wound environment.
Pressure injury neither too moist nor too dry
Maintain existing moisture level by:
- Using a collagen dressing to promote growth of tissue and blood vessels.
- Using dressings that are made from a woven or perforated material and to be placed directly over the wound then secured by a contact layer dressing.
- Using a transparent film dressing that adheres to the skin and helps maintain a moist wound environment. These types of dressings promote debridement and stimulate formation of granulation tissue.
Pressure injury is too dry
Add moisture by:
- Using a hydrogel dressing to promote hydration to the wound and soften dead tissue.
Other types of dressings
Composite
Combines two or more types of dressings into one depending on the stage of the wound.
Anti-microbial
Contains ingredients such as silver and iodine to protect your wound from bacteria.
What does research tell you?
Expert opinion recommends using a dressing that maintains an optimal level of moisture at the base of the pressure injury.
Strategies for managing pressure depend on:
- The location of your pressure injury
- Your circumstances and available resources.
Strategies to aid the healing process include:
- Full-time (24-hour) bed rest
- Limited time sitting with close monitoring
- A graduated sitting protocol for a healed pressure injury (see below for more details)
- Monitoring of equipment condition
- A positioning aid such as a heel wedge.
Graduated sitting protocol for pressure injury management
Perform a skin check prior to – and after – sitting at all times.
Day 1 | Sit up for 15 minutes twice a day | |
If skin condition does not deteriorate after the 1st day, increase sitting time as described on Day 2. | If skin condition does deteriorate after the 1st day of sitting, return to bed rest until re-evaluated by medical staff. | |
Day 2 | Sit up for 30 minutes twice a day | |
If skin condition does not deteriorate after the 2nd day, increase sitting time as described on Day 3. | If skin condition does deteriorate after the 2nd day of sitting, return to 15 minutes of sitting only. | |
Day 3 | Sit up for 1 hour twice a day | |
If skin condition does not deteriorate after the 3rd day, increase sitting time as described on Day 4. | If skin condition does deteriorate after 3rd day of sitting, return to 30 minutes of sitting only. | |
Day 4 | Sit up for 2 hours twice a day | |
If skin condition does not deteriorate after the 4th day, increase sitting time as described below this section. | If skin condition does deteriorate after 4th day of sitting, return to 1 hour of sitting only. |
Day 1 | Sit up for 15 minutes twice a day |
If skin condition does not deteriorate after the 1st day, increase sitting time as described on Day 2. If skin condition does deteriorate after the 1st day of sitting, return to bed rest until re-evaluated by medical staff. | |
Day 2 | Sit up for 30 minutes twice a day |
If skin condition does not deteriorate after the 2nd day, increase sitting time as described on Day 3. If skin condition does deteriorate after the 2nd day of sitting, return to 15 minutes of sitting only. | |
Day 3 | Sit up for 1 hour twice a day |
If skin condition does not deteriorate after the 3rd day, increase sitting time as described on Day 4. If skin condition does deteriorate after 3rd day of sitting, return to 30 minutes of sitting only. | |
Day 4 | Sit up for 2 hours twice a day |
If skin condition does not deteriorate after the 4th day, increase sitting time as described below this section. If skin condition does deteriorate after 4th day of sitting, return to 1 hour of sitting only. |
Sitting times can progress by doubling the overall length of time from the day before as long as skin checks demonstrate no new pressure-related problems.
Source: Adapted from Houghton PE, Campbell KE and CPG Panel (2013). Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for Clinicians.
Talk with your community nurse or GP before starting a graduated sitting protocol.
- Use pillows, cushions and positioning aids to:
- Bridge contacting tissues, including bony prominences
- Unload bony prominences
- Protect pressure injuries and other vulnerable areas of skin.
- Do not use closed cut outs in mattresses or donut type cushions, and avoid being positioned directly on your pressure injury.
Do you know?
Positioning in bed with the head of the bed elevated more than 30 degrees can cause destructive friction and shearing forces, especially over lower back/sacral region. Use the knee break to prevent sliding down the bed.
Education is essential so you and your caregivers know how to:
- Carry out repositioning manoeuvres safely, including correct positioning of pillows and wedges, and aids to reduce friction such as slide sheets.
- Avoid pinching of catheter tubing and wrinkling of your clothing under weight-bearing parts of the body.
Important Note
Do not place incontinence sheets over the top of your support surface as it negates the redistribution and relief of pressure.
Talk with your community nurse or GP before using any of the above-mentioned methods.
What does research tell you?
Expert opinion recommends the reassessment of the pressure-relieving performance of sitting support surfaces at least every 2 years, or sooner, if there is:
- A change in your health status, including weight or functioning level
- Wear and tear of equipment
- Development of a pressure injury
- A change in your living circumstances, care and support needs.
Support surfaces are broadly classified in 2 categories: reactive or active types.
Reactive or Static
A reactive support surface is a powered or non-powered support surface with the capability to change its load distribution in response to the applied load.
Type | Performance characteristic | Application |
|---|---|---|
Foam |
| Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation |
High-specification foam |
| Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation |
Static flotation air, gel or water |
| Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation |
Foam | |
|---|---|
Performance characteristic
| |
Application Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation | |
High-specification foam | |
Performance characteristic
| |
Application Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation | |
Static flotation air, gel or water | |
Performance characteristic
| |
Application Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation | |
Active or Dynamic
An active support surface is a powered support surface with the capability to change its load distribution properties, with or without the applied load.
Type | Performance characteristic | Application |
|---|---|---|
Alternating air pressure |
| Pressure injury prevention or treatment:
|
Alternating air pressure |
|---|
Performance characteristic
|
Application Pressure injury prevention or treatment:
|
Source: Modified from Houghton PE, Campbell KE and CPG Panel (2013). Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for Clinicians.
Do you know?
The optimal period for a change in position is still unknown. However, changing position every 2 hours is widely recognised as an effective and clinically useful strategy.
Talk to your community nurse or GP before deciding on a suitable support surface.
One size does not fit all
Consult a registered Dietitian for a comprehensive assessment to develop a personalised nutrition and diet plan, in consultation with your GP.
Your diet plan will tell you:
- How many calories to consume each day
- How much protein to include daily
- Which minerals and multivitamins you need to promote healing of your pressure injury
- Which supplements to take or avoid.
Important Notes
- Inadequate food intake, poor nutritional status, excessive nutrient and fluid losses, and unplanned weight loss impair wound healing.
- Low protein (albumin and prealbumin) values in your blood reflect the severity of illness or injury and the potential for the development or worsening of malnutrition, regardless of nutrition status.
- Inadequate fluid intake may result in dehydration, which plays a role in delayed wound healing.
- Effectively managing your bowel and bladder to avoid incontinence can also impact on the healing of your pressure injury.
Do you smoke? The most important thing you can do is quit.
What does research tell you?
Expert opinion recommends having an early assessment by a dietitian to provide optimal nutritional support for all people with a spinal cord injury who have a severe pressure injury, a pressure injury that is not healing at the expected rate, unintentionally lost weight or are at risk of malnutrition.
The two most common methods used to promote healing of a pressure injury are:
Electrical Stimulation
A small battery-like device sends an electrical current via two small rubber pads attached to the skin or surrounding a pressure injury.
This method is used for stage 2, 3 and 4 of pressure injuries.
Negative Pressure Wound Therapy
A suction is attached to a wound dressing that covers the pressure injury, which exerts carefully controlled suction or negative pressure. This action removes wound
and tissue fluid from the treated area
by draining it into a canister.
This drainage method is used for stage 3 and 4 pressure injuries.
The following interventions are less widely used for promoting healing of a pressure injury, and also have less evidence-based research:
- Maggot Therapy
- Electromagnetic Energy
- Ultraviolet Light
- Topical Oxygen
- Laser
- Hyperbaric Oxygen.
Talk to your community nurse or GP before using any of the above-mentioned methods.
What does research tell you?
Electrical stimulation has been shown to increase the proportion of healed pressure injuries when compared with no stimulation. However, the research evidence to date supporting the positive effects of electrical stimulation is insufficient to support its widespread use.
Research evidence supporting the positive effects of negative pressure wound therapy is minimal. In comparison, a standard dressing has better outcomes and lower intervention costs.
Surgery can play an important part in the management of pressure injuries that are non-responsive to other strategies, e.g., in stage 3 or 4 pressure injuries.
There are a range of surgical interventions:
- Surgical debridement or removing dead tissue
- Direct wound closure
- Skin grafting
- Skin-muscle flap repairs.
Important Note
Consulting a Specialist Spinal Plastics or Skin Care Service for a comprehensive interdisciplinary evaluation is essential before deciding to undergo surgical intervention.
Advantages of surgical intervention:
- Definitive wound debridement with skin and soft tissue coverage
- Improved blood supply
- Improved healing with removal of underlying bony infection called osteomyelitis
- Improved function and independence.
Important Note
Surgery is a huge commitment requiring total bed rest in the prone position for months in hospital prior to and after surgery. There is also a risk of further skin breakdown after the surgery.