SWM Module 14: Wound Care - Pressure Injuries Flashcards

Est. a repositioning schedule to relieve pressure on vulnerable areas every 1-2 hrs.

For patients at high risk of PIs, repositioning should be the PRIORITY because it helps redistribute pressure and prevents prolonged pressure on the same areas, which is the primary cause of PIs. While nutrition is important, it is secondary to the immediate need to offload pressure. Moisture management is important but does not directly address the key risk of pressure, which is the main cause of injury in high-risk patients. Foam cushions may help with pressure distribution, but without regular repositioning, they are insufficient to prevent PIs on their own.

Limited mobility, poor nutrition, moisture, and comorbidities elevate PI risk. High-risk patients require frequent repositioning, advanced support surfaces, and nutritional monitoring.

Adjust care plans for high-, moderate-, and low-risk patients with strategies ranging from proactive skin care to basic prevention routines.

Interdisciplinary collaboration is integral to providing effective patient-centered care

• Redistribute Pressure: Refers to a support surface’s ability to spread body weight across a wider area, which helps reduce pressure on specific points and lowers the risk of PIs.
• Enhance Immersion: Indicates how much the body sinks into the support surface. Deeper immersion (e.g., sinking 6 inches) leads to improved pressure distribution compared to shallower immersion (e.g., sinking 4 inches).
• Promote Envelopment: Describes how well a support surface conforms to the body's shape, reducing concentrated pressure on the skin and improving comfort.

• Patient Immobility: Assess the level of immobility or inactivity.
• Pressure Redistribution Needs: Consider features that enhance pressure redistribution, control the microclimate, and reduce shear and friction.
• Patient Size and Weight: Determine if the patient needs a bariatric bed based on their size and weight.
• Patient Positioning: Ensure the patient can be repositioned to offload pressure from affected areas.
• Fall and Entrapment Risks: Consider the risks of falls and entrapment associated with the support surface, such as overlays.
• Patient Preferences: Factor in the patient’s previous experiences and preferences with support surfaces.

Mattresses and overlays that are designed to reduce the risk of PIs by periodically redistributing pressure across different areas of the body (Baranoski & Ayello, 2020). These surfaces use air cells that inflate and deflate cyclically, creating alternating high and low-pressure zones. The alternating inflation and deflation of air cells shift pressure from one area of the body to another.

These beds are filled with tiny beads suspended in warm air, creating a fluid-like effect. When a patient lies on the bed, their body is partially immersed in the beads, which contour around them, distributing their weight evenly. The fluid-like environment allows the patient’s body to float, minimizes shear and pressure, boosts immersion and envelopment, significantly reducing the risk of PIs.

These beds also help manage the microclimate by wicking away moisture and maintaining a consistent temperature. This helps keep the skin dry and reduces the risk of maceration and moisture-associated skin damage (MASD).

For use with patients who have an unstable spinal cord injury.

Consider an air-fluidized bed for patients with stage 3 or 4 PIs (EPUAP et al., 2019).

Use reactive air or high-specification reactive single-layer foam mattresses or overlays.

Choose a support surface that offers better pressure redistribution, shear reduction, and microclimate control. This is especially important if:

• The patient cannot be repositioned off PI areas.
• The patient has injuries on two or more turning surfaces.
• The injury fails to heal or worsens.
• The patient is at high risk for additional PIs or is experiencing inadequate pressure redistribution, also commonly referred to as “bottoming out”

Consider alternating pressure, low air loss beds, or air-fluidized surfaces, particularly for patients with stage 3 or 4 PIs. However, be cautious with air-fluidized beds as they can increase the risk of dehydration due to high airflow.

Use a heel suspension device to offload pressure completely from the heels.

*A heel suspension device is MOST appropriate to promote healing because it effectively offloads all pressure from the heel. Placing a pillow under the knees to elevate the legs may inadvertently increase pressure on the heels rather than relieve it. While a dressing may protect the skin, it does not adequately offload pressure from the heel. While more frequent turning is beneficial, it may not fully address the need for targeted offloading of the heel.

Redistribute pressure, enhance immersion, and conform to the body’s shape to minimize concentrated pressure points and improve comfort.

Use foam overlays or reactive mattresses; for those with existing PIs or severe injuries, consider high-tech solutions like alternating pressure or low air loss beds to manage microclimates and prevent worsening.

ift high-risk areas entirely off surfaces, reducing pressure on bony prominences such as heels or elbows.

wear, ensure proper fit and positioning, and avoid excessive bedding that can hinder pressure redistribution. Perform hand checks or use pressure mapping to detect "bottoming out."

These patients may require careful repositioning strategies that account for hemodynamic and oxygen stabilization. These strategies include frequent, small, gradual shifts in body positions.

• Include techniques like 30-degree lateral positioning and the use of assistive devices to reduce friction and shear.
• Be done frequently, especially when signs of pressure-related skin changes are observed.
• Provide optimal offloading and pressure redistribution.
• Avoid positioning patients directly on areas with erythema, PIs, or medical devices.
• Use assistive devices like transfer sheets to reduce friction and shear.
• Consider potential pressure points from bedding, shoes, surgical stockings, medical devices, or wheelchair foot pedals.

Keep the head of the bed elevated no more than 30° to reduce pressure (EPUAP et al., 2019).

Rotate patients 30° on their side in a lateral motion to offload pressure from the greater trochanters and distribute weight on fattier tissue areas.

The semi-Fowler's position is preferred when elevation above 30° is medically necessary.

• Under the legs: To elevate the heels off the bed
• Between the ankles: Prevents friction and pressure between the ankles
• Between the knees: Maintains proper alignment and reduces pressure
• Behind the back: Supports the back in a lateral position
• Under the head: Ensures proper neck alignment and comfort

Heels are one of the most common areas on which a PI can develop in bedbound patients.

Ensure heels are free of the bed surface, using a pillow or foam cushion under the calves for short-term relief (stage 1 or 2 PIs) (EPUAP et al., 2019). Some facilities may have specially designed suspension devices for heels.

Long-Term Support

Consider heel suspension devices for long-term use, especially in patients with stage 3 or greater PIs (EPUAP et al., 2019). When positioning heels, ensure the pressure is taken off completely so that the patient's leg weight spreads out over the lower part of the leg. Be careful not to put pressure on the Achilles tendon and the popliteal vein behind.

Dynamic Weight Shifting

This means leaning the chair back and lifting the legs to decrease stress on the lower back. Ensure the feet are well supported and angle the seat from 25° to 30°. This helps avoid sliding down and reduces stress on the lower back, sitting bones, and tailbone.

Repositioning should occur every hour for seated patients (National Pressure Injury Advisory Panel [NPIAP], 2023). Encourage pressure relief maneuvers such as:

• Weight shifting during functional activities
• Standing up and sitting back in the chair
• Leaning forward or sideways
• Arm lifts/pushups

Micro shifts (5° to 10° or a 5 to 10 second lift) with a return to the same position may not be sufficient for pressure relief

Use continuous lateral rotation therapy and maintain the patient in a 30° lateral position.

Continuous lateral rotation therapy combined with the 30° lateral position helps redistribute pressure and reduce the risk of PIs, particularly when unable to mobilize or sit out of bed. Prone positioning can increase the risk of PIs on the face and chest if not carefully managed. Elevating the head of the bed to 45° and placing a pillow under the knees may increase pressure on the sacrum and heels, leading to a higher risk of PIs. Repositioning once per shift is insufficient for preventing pressure injuries in a high-risk, immobile patient.

Tailor repositioning plans to the patient’s condition, mobility, and risk level. Use strategies like the 30° lateral position or continuous lateral rotation therapy to offload pressure for immobile patients.

Use tools such as the “5 Pillow Rule” for proper alignment, heel suspension devices to protect vulnerable areas, and friction-reducing sheets to minimize shear forces.

Facilitate early movement, including sitting and ambulation, as soon as medically feasible. Gradually increase sitting duration while monitoring tissue tolerance.

For chair-bound patients, implement dynamic weight-shifting techniques like leaning, standing, or arm push-ups to relieve pressure on the sacrum, sitting bones, and heels.

• Inspect the skin for discoloration using tangential light or slightly moisten the skin.
• Palpate the skin for temperature, changes in consistency, and edema:
  • Cool skin may indicate underlying necrosis.
  • Induration and hardness may signal early skin damage.

ITD appears as a mirror image in skin folds, as linear and partial-thickness wounds (Baranoski & Ayello, 2020). These may progress from mild redness to intense inflammation, with erosion, oozing, exudate, maceration, and crusting.

ITD, or intertrigo , is an inflammatory condition that occurs in opposing skin surfaces due to moisture buildup (Baranoski & Ayello, 2020). It commonly affects skin folds under the breasts, in the axillae, or the inguinal and abdominal regions, especially in those with obesity.

• Use a personalized skincare regime.
• Avoid irritants or friction with skin care.
• Gently pat the skin dry and consider using absorptive fabrics to reduce moisture.

Thrive in warm, moist environments (Flowers, 2020). Candidiasis is one of the most common skin diseases in the elderly due to alterations in the skin barrier function of the skin. Diagnosis is usually made on basis of clinical presentation but can be confirmed by skin scrapings under a microscope.

Consolidated or patchy areas with small round red papules, pustules, and satellite lesions. The area is typically tender and pruritic.

They may also appear as partial-thickness wounds with a beefy pink base, although not all skin rashes are caused by Candida; some may be due to dermatophytes or bacteria.

You will often see them in areas, such as:

• Axillae
• Groin
• Peristomal skin
• Body folds
• Gluteal region
• Between the breasts

• Exposure to excessive moisture
• Antibiotic/steroid use
• Poorly controlled diabetes
• Poor hygiene
• Weak immune system

Candida presents as a bright red central area with satellite lesions in light-skinned patients. In darker-skinned patients, it may appear as a lighter or darker skin tone or develop into a darker red or purplish hue.

• Provide meticulous skincare and hygiene.
• Use pH-balanced, no-rinse cleansers.
• Ensure thorough drying of the skin.
• Apply over-the-counter (OTC) or prescription antifungal powders or creams (e.g., Nystatin, Ketoconazole, Miconazole)

• It's crucial to continue using the antifungal for the full course of 2 weeks and then reassess, even if symptoms improve, to ensure the infection is completely eradicated.
• Overusing antifungal products can cause skin irritation, redness, burning, stinging, swelling, or other side effects including antifungal resistance.

• InterDry® Moisture Wicking Fabric
• Remedy® DriGo-HP™ Antibacterial Wicking Sheets
• DermaTex™ Ag Moisture Wicking Fabric

Severe or non-responsive cases may require systemic treatment.

Applied to the skin after drying helps keep the skin intact and reduce the risk of PIs. Barrier creams form a protective layer on the skin, preventing moisture from urine or feces causing irritation or breakdown. They are essential for patients with frequent incontinence to protect the skin from MASD.

• Effective for creating a seal that reduces transepidermal water loss, but can leave a greasy residue that interferes with dressing adherence

• Offers mechanical protection and repels irritants from the skin but is thicker and more difficult to remove

• Permeable to water vapor, allows the skin to breathe while preventing moisture-associated damage and less greasy residue than petroleum

MASD results from prolonged exposure to moisture rather than pressure (Baranoski & Ayello, 2020).

• Incontinence-associated dermatitis (IAD)
• Peristomal dermatitis
• Intertriginous dermatitis (intertrigo)
• Periwound maceration

A subset of MASD, IAD occurs due to prolonged exposure to urine or stool. It commonly affects the buttocks, perineum, inner thighs, or groin (Baranoski & Ayello, 2020). IAD presents as consolidated or patchy areas of skin damage or partial-thickness wounds without necrosis, which is associated with pressure-related ischemia.

Blisters caused by pressure from leg bands or waistbands of incontinence briefs are classified as PIs. However, blisters or skin tears resulting from adhesive tabs are categorized as medical adhesive-related skin injuries (MARSI).

Medical adhesive-related skin injuries

Use a pH-balanced no-rinse cleanser and moisture barrier cream.Using a pH-balance no-rinse cleanser and moisture barrier cream would be BEST because they protect it from further moisture-related damage and skin breakdown. Applying a petrolatum-based ointment may offer some protection but does not address the need for regular cleansing and immediate intervention. Zinc oxide barriers should not be scrubbed off with every cleansing and reapplication. Hydrocolloid dressings are not the best first-line intervention for early skin breakdown due to moisture; managing incontinence directly is more important.

Use pH-balanced cleansers and barrier products to protect the skin from breakdown. Avoid over-cleaning, hot water, or harsh rubbing to maintain skin integrity, especially after incontinence episodes.

Monitor for moisture buildup, redness, or signs of Candida infections, especially in skin folds. Treat intertriginous dermatitis (ITD) with gentle drying and antifungal creams as needed.

Differentiate between pressure injuries, MASD, and IAD (incontinence-associated dermatitis) for appropriate intervention. MASD results from prolonged moisture exposure and may require targeted hygiene and barrier protection.

Use no-rinse cleansers, pre-moistened wipes, and moisture barrier creams to protect sacral and perineal skin from irritation. Incorporate absorbent pads, briefs, or fecal control systems to reduce moisture exposure.

T

Tissue management

I

Infection control and inflammation

M

Moisture balance

E

Edges of wound

R

Repair/regeneration

S

Social factors

Debridement promotes healing by removing devitalized tissue and biofilm and should align with the patient’s condition and management goals.

True

Cleanse the wound and peri-wound with every dressing change unless contraindicated. Choose a noncytotoxic cleanser for uninfected wounds or a cytotoxic one for infected wounds. Irrigate at appropriate pressure and address tunneling and undermining.

Remove necrotic tissue or biofilm to promote healing. Methods include surgical (sharp), autolytic, bio-surgical (maggots), enzymatic, and mechanical debridement. Select the method based on the patient's condition, pain tolerance, and management goals.

B

Biosurgical (maggots)

E

Enzymatic

A

Autolytic

M

Mechanical debridement

S

Sharps (conservative, surgical)

Maintain a moist wound environment. Match dressing type to wound characteristics (e.g., alginates for drainage, hydrogels for dry wounds). Use silicone-based dressings for fragile skin to minimize trauma.

Bio surgical - maggots

Enzymatic

Autolytic

Mechanical debridement

Sharps (conservative, surgical)

Monitor for signs of infection, including delayed healing, redness, or exudate. Address biofilm based on clinical signs or tissue biopsy if available. Use systemic antibiotics only for systemic infection (e.g., sepsis, cellulitis).

Mechanical, autolytic, enzymatic, and/or biological methods may be considered if there is no urgent need for sharp debridement (EPUAP et al., 2019).

• Biofilm (suspected or confirmed).
• Delayed wound healing (e.g., > 4 weeks).
• Failure of standard wound care measures, including antibacterial therapy.

dressing change

Should NOT be disturbed in ischemic limbs and heels.

* However, removal of eschar may be considered if wound infection is suspected.

• Redness
• Pain or tenderness
• Swelling
• Fluctuance
• Crepitus
• Wound odor
• Exudate

Is a wave-like or boggy, soft, "squishy" sensation felt when palpating a swelling or lump

surgical debridement

DRESSING: To control drainage while keeping it off the peri-wound:

• Calcium alginate
• Absorbent dressings containing collagen
• Composite
• Foam
• Hydrocolloid

DRESSING:

• Silver-impregnated
• Cadexomer iodine
• Polyhexamethylene biguanide (PHMB)

DRESSING:

• Collagenase (enzymatic)
• Medical grade honey-impregnated (autolytic)
• Hydrocolloid (autolytic)
• Maggots (biologic)

DRESSING: To add moisture-

• Collagen gel
• Composite
• Hydrocolloid
• Hydrogel
• Transparent film
• Medical grade honey

Silicone-based

Characteristics that indicate the presence of infection

• Cadexomer iodine
• Silver
• Medical grade honey
• Methylene blue
• Hypochlorous acid
• PHMB
• Sodium hypochlorite
• Povidone Iodine
• Acetic acid

The choice of antiseptic depends on the patient and the wound's condition.

Systemic antibiotics

Severe, limb- or life-threatening infections

Calcium alginate dressing

Calcium alginate dressings are highly absorbent, making them ideal for wounds with moderate to heavy exudate. They help manage wound drainage while also promoting autolytic debridement, which assists in removing slough and necrotic tissue. Hydrogel dressings are more appropriate for dry wounds, as they add moisture to the wound bed. Transparent film dressings are best used for superficial wounds or wounds with minimal exudate, as they do not absorb exudate and are not suited for wounds with necrotic tissue. While collagenase dressings are useful for enzymatic debridement, they are not the best choice for wounds with high exudate because they do not manage moisture as effectively as calcium alginate.

Calcium alginate

1.2 to 1.5 g/kg/day or adjust based on patient needs

30-35 kcal/kg/day

Add to diet if nutritional needs are unmet

Add to diet if nutritional needs are unmet

Products that have nutrients—specifically vitamins, minerals, or fiber—added to them that are not naturally present or are present in small amounts

• High caloric and protein intake.
• Supplements with arginine, zinc, and antioxidants as appropriate.

for draining wounds

dry wounds

Infected wounds

Monitor for infection signs like delayed healing or exudate, using antiseptics like silver or medical honey as needed. Debride unstable eschar carefully to remove biofilm or necrotic tissue but avoid disturbing dry eschar on ischemic areas like heels.

Patients with Stage 2 or higher PIs require 1.2 to 1.5 g/kg/day of protein and 30 to 35 kcal/kg/day. Add supplements like arginine, zinc, and antioxidants to support healing in malnourished or at-risk patients.