Pressure Injury Management

Risk Factors and Contributing Factors

Pressure injuries can progress from one stage to another due to inadequate pressure relief, competing priorities in care settings, insufficient staffing capacity, nutritional deficiencies, and lack of appropriate support surfaces, as recommended by the American College of Nursing and the International Journal of Nursing Studies guidelines 1
Inadequate dietary intake and lack of essential micronutrients can contribute to pressure injury progression, emphasizing the need for adequate nutrition and supplementation 2, 3

Implement turning schedules every 2-4 hours to prevent pressure injuries in high-risk patients, such as quadriplegic patients, as recommended by the American Society of Anesthesiologists 2, 3, 4
Ensure adequate dietary intake of 30-35 kcal/kg/day and 1.25-1.5 g protein/kg/day to enhance wound healing, as suggested by the National Pressure Injury Advisory Panel and supported by moderate-quality evidence 2, 3
Supplement micronutrients that enhance wound healing, including Vitamin B6, B12, folate, Zinc, Vitamin C, and Vitamin D, to promote faster healing 2, 3, 4
Use specialized support surfaces, such as air-fluidized beds, to reduce pressure on the sacral area and promote wound healing, with moderate-quality evidence supporting this intervention 3

Regularly assess wound size, depth, and characteristics to monitor progress and adjust treatment plans, as recommended by the Wound, Ostomy and Continence Nurses Society 2, 3, 4
Monitor for signs of local infection, including increased pain, erythema, edema, increased warmth, purulent drainage, and malodor, to promptly address complications 2, 3, 4
Assess for biofilm formation, including low-level chronic inflammation, delayed healing despite adequate care, increased exudate, and poor granulation 4

Topical corticosteroid therapy, such as triamcinolone, combined with foam dressing for 7-10 days, has shown effectiveness in resolving hypergranulation tissue, with a resolution rate of 95.7% 2, 5
Silver nitrate cauterization may be considered if corticosteroid treatment fails, but it can be painful and may lead to scarring, as noted by the American College of Surgeons 2, 5, 4
Surgical debridement may be necessary for cases that don't respond to topical treatments, and patients eligible for surgery should be evaluated for possible flap coverage after controlling hypergranulation 2, 4

Moisture-balanced dressings, such as alginate or hydrofiber dressings for moderate to heavy exudate, and hydrocolloid dressings for light to moderate exudate, should be selected, considering antimicrobial dressings if signs of local infection or biofilm are present 3, 4

Ensure multidisciplinary care involving wound specialists, rehabilitation specialists, nutritionists, and possibly surgical teams is vital for effective management of hypergranulated wounds 4
Control spasticity, which is a critical but often overlooked factor in pressure injury management, to prevent treatment failure, as recommended by the American Academy of Physical Medicine and Rehabilitation 2, 4
Limit use of systemic antibiotics to only when clear evidence of infection exists, to avoid overuse and resistance, as recommended by the Infectious Diseases Society of America 2, 3, 4
Common pitfalls to avoid include neglecting to assess for biofilm, using inappropriate dressings, failing to address nutritional deficiencies, overusing antibiotics without clear evidence of infection, and inadequate pressure redistribution, as emphasized by the Clinical Infectious Diseases guidelines 4

Pressure injuries are classified into four distinct stages based on the depth of tissue damage, with each stage requiring specific management approaches, and stage IV pressure injuries have a high risk of developing osteomyelitis, with prevalence ranging from 17% to 58% in patients with stage IV pressure injuries 4
Stage 2 pressure injuries are characterized by partial-thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough, and may also present as an intact or ruptured serum-filled blister 4
Stage 3 pressure injuries are characterized by full-thickness tissue loss exposing subcutaneous fat, with slough possibly present but not obscuring the depth of tissue loss 4, 6