Understanding Pressure Injuries in Long-Term Care
A pressure injury, historically known as a pressure ulcer or bedsore, is localized damage to the skin and underlying soft tissue. It typically occurs over bony prominences, such as the sacrum, heels, elbows, and hips, but can also be caused by medical devices. For residents in long-term care, where mobility is often limited, these injuries are a significant and serious health concern that can lead to pain, infection, and reduced quality of life. Unlike minor skin irritations, pressure injuries can progress rapidly and are a key indicator of the overall quality of care provided.
The Core Causes: Pressure, Friction, and Shear
Pressure injuries result from intense or prolonged pressure, often combined with friction and shear [1]. Pressure compresses tissue between a bony prominence and an external surface, restricting blood flow and causing damage [1]. Friction occurs when skin rubs against a surface, potentially removing protective layers [1]. Shear happens when the skin stays put while underlying tissues shift, damaging blood vessels internally [1].
Who is at Risk for a Pressure Injury in Long-Term Care?
Several factors increase the risk of pressure injuries in long-term care residents:
- Immobility: Limited ability to change position is a major risk [1].
- Incontinence: Moisture from bodily fluids weakens skin and increases vulnerability [1].
- Poor Nutrition: Lack of protein and other nutrients impairs tissue repair [1].
- Age-Related Skin Changes: Older skin is thinner and more fragile [1].
- Underlying Medical Conditions: Diseases affecting circulation, like diabetes, and conditions causing weakness or decreased sensation increase risk [1].
The Staging of Pressure Injuries
The National Pressure Injury Advisory Panel (NPIAP) classifies pressure injuries into stages based on tissue damage [1]. This system helps guide treatment and management. The stages include: Stage 1 (intact skin with non-blanchable redness), Stage 2 (partial-thickness skin loss), Stage 3 (full-thickness skin loss with visible fat), Stage 4 (full-thickness skin and tissue loss with exposed bone, muscle, etc.), Unstageable (damage extent obscured by slough or eschar), and Deep Tissue Pressure Injury (persistent discoloration of intact skin) [1].
Prevention Strategies in Long-Term Care
Preventing pressure injuries is crucial and involves multiple strategies [1]. Key interventions include regular repositioning of residents to relieve pressure points, systematic skin assessments to detect early signs, and using pressure-redistributing surfaces like specialized mattresses and cushions [1]. Maintaining good nutrition and hydration, along with effective moisture and incontinence management, are also vital for skin health [1].
Comparison of Key Prevention Strategies
| Strategy | Description | Best For | Considerations |
|---|---|---|---|
| Repositioning Schedule | Routinely changing a resident's position to relieve pressure on specific areas. | All at-risk residents, especially those with limited mobility. | Requires consistent, documented adherence by care staff. Needs to be individualized based on risk. |
| Pressure-Redistributing Surfaces | Using specialized mattresses, overlays, or cushions to distribute body weight more evenly. | High-risk individuals, or those with existing pressure injuries. | Can be expensive; need to be selected based on the resident's specific needs and mobility. |
| Nutritional Support | Providing a diet rich in protein, vitamins, and minerals; may include supplements. | Individuals with poor appetite, weight loss, or existing wounds. | Requires regular monitoring and collaboration with dietary staff and physicians. |
| Moisture Management | Using barrier creams, absorbent products, and frequent cleaning to keep skin dry. | Incontinent residents or those with excessive perspiration. | Incontinence products should be changed promptly. Barrier creams should be applied properly, not heavily. |
| Physical Activity | Encouraging exercise and movement as much as possible, including transfers from bed to chair. | Mobile residents or those undergoing rehabilitation. | Must be done safely, often with supervision or physical therapy support. |
Treatment and Management of Pressure Injuries
Treating pressure injuries requires prompt intervention [1]. Management typically involves removing pressure from the affected area, cleaning the wound gently, and debriding (removing dead tissue) if necessary [1]. Appropriate dressings are used to create a suitable environment for healing, and infection control measures, including antibiotics, may be needed [1].
The Importance of a Collaborative Approach
Effective pressure injury management is a team effort involving residents, families, and healthcare professionals such as physicians, nurses, dietitians, and therapists [1]. Clear communication and documentation are essential, and a wound care specialist can be a valuable team member [1].
Legal and Ethical Considerations
Preventable pressure injuries in long-term care can raise legal and ethical concerns, potentially indicating a failure in the standard of care [1]. This can lead to legal action for negligence [1]. Facilities have a duty to implement preventive measures and provide appropriate treatment [1]. For more information on preventing pressure injuries, see the National Pressure Injury Advisory Panel (NPIAP) guidelines here.
Conclusion
A pressure injury is a significant health risk in long-term care, resulting from sustained pressure and other forces [1]. While serious, many can be prevented through consistent monitoring, repositioning, and supportive care [1]. Understanding the causes, stages, and prevention strategies is vital for protecting the health and well-being of residents [1].
