Understanding the Mechanisms of Pressure Injury Formation
A pressure injury, also commonly referred to as a bedsore, pressure ulcer, or decubitus ulcer, results from several key factors working together [1, 2]. While pressure is the primary culprit, other forces like friction and shear play a significant role, especially for residents in long-term care facilities who may be immobile or have limited sensation [1, 2].
- Pressure: Constant pressure on a specific area compresses soft tissue between bone and a surface, restricting blood flow and potentially causing tissue death [1, 2].
- Friction: Skin rubbing against surfaces damages the top layers, making skin fragile [1]. This is common during repositioning without proper lifting [1].
- Shear: Skin and underlying tissue move in opposite directions, like sliding down in bed, stretching and tearing blood vessels and tissue [1].
The Official Staging of Pressure Injuries
Healthcare professionals use a standardized staging system by the National Pressure Injury Advisory Panel (NPIAP) to assess and treat these wounds [3]. The stages indicate the extent of tissue damage [3].
The Four Primary Stages
Pressure injuries are classified into stages based on their severity [3].
- Stage 1: Intact skin shows non-blanchable redness, possibly with different coloration on darker skin [3].
- Stage 2: Partial-thickness skin loss exposes the dermis, appearing as a pink/red, moist wound or a blister [3].
- Stage 3: Full-thickness skin loss reveals adipose tissue, but not bone or muscle, and may include undermining or tunneling [3].
- Stage 4: Full-thickness skin and tissue loss exposes fascia, muscle, tendon, ligament, cartilage, or bone, possibly with slough or eschar [3].
Other Classifications [3]
- Unstageable: The full extent of tissue damage is hidden by slough or eschar, preventing staging.
- Deep Tissue Pressure Injury (DTPI): Intact or damaged skin shows persistent deep red, maroon, or purple discoloration, indicating underlying damage.
Risk Factors and Prevention in Long-Term Care
Several factors increase a resident's risk, making a proactive approach to care essential [1, 2].
Key Risk Factors [1, 2]
- Immobility: Bed-bound or chair-fast residents who cannot reposition themselves are at highest risk.
- Incontinence: Moisture from urine and feces softens and breaks down skin.
- Poor Nutrition and Hydration: Inadequate intake compromises skin integrity and healing.
- Advanced Age: Older adults' skin is thinner, drier, and less elastic.
- Medical Conditions: Chronic illnesses can affect blood flow and sensation.
Preventive Measures [1, 2]
- Repositioning: Regular, scheduled repositioning (e.g., every two hours in bed, more often in a chair) is fundamental and should be individualized.
- Skin Care: Gentle cleansing, moisturizing, and using barrier creams protect skin from moisture.
- Pressure-Redistribution Surfaces: Specialized mattresses and cushions help reduce pressure points.
- Nutritional Support: Ensuring adequate diet and hydration is vital for healthy skin and healing.
Prevention vs. Avoidable Injuries
While some pressure injuries are medically unavoidable due to severe clinical conditions, many are considered avoidable and may indicate deficient care [1]. Facilities must implement comprehensive prevention protocols [1].
| Feature | Avoidable Pressure Injury [1] | Medically Unavoidable Pressure Injury [1] |
|---|---|---|
| Cause | Lack of adherence to standard care, such as improper repositioning, inadequate skin care, or neglected nutrition. | Arises despite consistent, comprehensive, evidence-based care being provided. |
| Contributing Factors | Systemic issues within the facility, including understaffing, lack of training, or failure to use appropriate equipment. | Severe, irreversible clinical conditions of the resident that impair healing, circulation, or skin integrity. |
| Outcome | Can lead to regulatory violations and potential liability for the facility. | Often documented as an expected complication of an underlying severe illness or end-of-life status. |
| Documentation | Reflects a lapse or failure in the implementation of the resident's care plan. | Shows a comprehensive care plan was in place and followed, with clear documentation of the resident's specific clinical factors making the injury unavoidable. |
The Role of Documentation and Education
Comprehensive documentation is essential for tracking skin integrity and care interventions [1]. Continuous education and training for all staff ensure consistent and high-quality care [1].
Conclusion: Proactive Care is Key
Understanding and preventing pressure injuries is core to quality care for long-term care residents [1]. Recognizing causes, risk factors, and stages, and implementing proactive strategies, can significantly reduce these painful injuries [1]. A collaborative, vigilant, and educational approach protects residents' health and dignity [1]. For more information on assessing and managing these injuries, consult the {Link: NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK553107/} [3].
