The Pressure is On! Prevent Pressure Injuries and Promote Skin Health

November 17^th is National Pressure Wound Awareness Day. According to National Pressure Injury Advisory Panel (NPIAP), 2.5 million people develop pressure injuries every year with 60,000 people dying every year as a direct result of pressure injuries. Not only is there a high cost of life, the financial burden related to pressure injury medical care in 2019 was estimated to be 26.8 BILLION DOLLARS!

A pressure injury, also known as a bedsore, pressure ulcer, or decubitus ulcer, occurs when different types of force, such as pressure, friction, or shear, are applied to the surface of the skin.  This usually occurs over bony areas and prominences (see the image).

Many pressure injuries are preventable.  But it takes awareness of people who are supporting at-risk individuals to have keen observation skills and knowledge of how to prevent injuries from happening.

Think about this. How many times a day do you reposition yourself? I know that since COVID-19, I have found that I am sitting for longer periods of time at my desk.  I also fidget around more frequently. But rarely do I think about doing it.  Our bodies tend to signal us when it is time to adjust our position and increase that blood flow to areas that have been impaired. But what if you were limited in that ability to either recognize that signal or to reposition yourself, relying on someone else to help you get comfortable? 

Assessing the appearance of the skin is a good start, but recognizing the overall conditions that could lead to the progression of skin breakdown and understanding how to best protect the skin in the first place are essential parts of prevention. Another important component is to maximize the individual’s capabilities.  This can be done by helping to develop their role on how they can actively take part in their care, to the best of their ability.

In my past experience, while working with an individual who was in a motorized wheelchair, very capable of making her needs known, we began discussing her level of comfort and history of skin breakdown. She enjoyed the independence she gained by being up in her wheelchair.  The freedom of mobility was something that she valued. She did not, however, enjoy when her buttocks were sore and she experienced pressure injuries. During those instances she had to be out of her wheelchair for extended periods of time.  She also indicated that she perceived it as a “bother” to ask staff to continually transfer her from wheelchair to recliners, or bed, or other areas that may have been more comfortable for a short period of time. By sharing information with this young woman regarding the effects of pressure on the body, she was able to understand the importance of taking little breaks out of the wheelchair and how that would help to protect her body from breakdown. We also talked about how important it is to make it known to staff when she was experiencing discomfort.  By protecting herself, she could continue to experience the freedom of being in her wheelchair and reduce the possibility of skin breakdown.  We also reinforced that by communicating more openly with the staff about her needs, and in turn their assurance to her that they were more than willing to assist her with positioning and transfers,  enabled  her to be a better advocate for herself and her health.

Let’s talk about who is at risk? The following conditions put people at risk and the more risk factors a person has, the greater their chances of developing a pressure injury.

Risk Factors or Conditions that Increase Risk:

• Impaired mobility or limited ability to reposition themselves
• Poor nutrition or hydration
• Urinary or fecal incontinence
• Elderly-consider also that people with intellectual and developmental disabilities (IDD) can experience accelerated aging.  So what we may see in someone without IDD who is 70-80, could occur in someone who is 60-70 with IDD.
• Obesity
• Decreased sensation due to nerve damage or spinal cord conditions
• A prosthetic device
• Diagnosis of a condition that affects blood flow such as diabetes or a vascular condition
• Inability to communicate effectively
• History of pressure injuries

There are tools such as the Braden Scale that should be completed to determine a person’s level of risk for skin breakdown and pressure injuries. Once someone has been identified as being at risk, it is important to identify the steps to put in place to prevent pressure injuries from occurring. Prevention depends on the factors at play.

• Skin Assessment: After the assessment for risk has been completed, it is essential that routine skin inspections are being done. The skin should be examined for signs of pressure damage. Check skin color. Is there any redness noted? An early sign is called non blanching erythema. This is when the area where the injury noted is reddened and when touched it does not turn white and then return to normal skin color, instead the area only remains red. Is there bruising or discoloration?  Other signs of impaired skin integrity could include warmth which could indicate infection. Cool areas may indicate impaired circulation.  There may be noted areas of raised hardened skin, dry, cracked areas, or skin that is excoriated – where there is chafing or abrasions. It is important to be thorough with this assessment. Times that may be best are when assisting with hygiene, when helping to get ready to go to bed, or when assisting with getting dressed in the morning.

• Skin Care: Keeping skin clean and dry is important when reducing risk of pressure injuries.  Using mild soap for hygiene and a patting motion when drying instead of rubbing the skin can help reduce skin irritation and limit skin integrity disruption. Someone who is incontinent of bowel or bladder, perspires frequently, has abdominal folds, or women with large or heavy breasts, would require much more attention to ensure the skin is free from moisture and bacteria. Take the time to examine folds and creases for any signs of breakdown. A person may require a barrier cream to help reduce skin breakdown. It is recommended to discuss which of these would be most beneficial with the medical provider before applying anything to the area. 

• Positioning and Repositioning: A person should be repositioning themselves or with assistance, regularly. Some recommendations state that for someone in a wheelchair, they should be shifting weight, with or without assistance, every 15 minutes and reposition every hour. If in bed, it is recommended that repositioning occur at a minimum of every two hours. Adaptive equipment such as wedges, mattresses, cushions, or heels up devices can be helpful. These can be utilized so that there is reduced pressure on the bony prominences and other areas of the body prone to breakdown. When positioning someone it is important to ensure that the sheets and bedclothes, as well as their clothing, are not bunched up underneath them. The head of the bed should be elevated only as far as is comfortable for the person, unless otherwise ordered. Use mechanical lifts; lift the person to transfer instead of dragging. If the person is dependent on a wheelchair, ensure that it is appropriately tailored to their physical needs.  Physical and occupational therapy can be of assistance in evaluating and determining best practices. These resources can ensure the person has the proper adaptive tools necessary to support them in reducing their risk and may even have recommendations for activities that promote overall good health.

• Diet-Nutrition and Hydration: A person’s intake can impact their body’s ability to have healthy skin, as well as to regenerate cells and to heal itself. It may be necessary to have a dietician or nutritionist evaluation.  If someone is not getting enough nutrition or the proper nutrition, it may be determined that additional supplementation is necessary such as protein shakes, vitamins, or additional fluids. Lab tests may be done to determine what the person’s needs may be, as protein is an essential building block for cell growth.

Prevention of pressure injuries requires excellent observation skills and knowledge of risk factors. Early detection and intervention can save someone from pain, risk of infection, loss of ability to participate in daily activities, and improve their quality of life. It is easier to implement preventative strategies early on and reduce the possibility of skin breakdown, pressure injuries, and the associated complications before they occur.

The HCQU has a more detailed resource booklet. Click here to download a copy of our Preventing Pressure Injuries Booklet. We also have a comprehensive list of wound care specialists for the counties we serve. Click here to download a copy of our Wound Care Specialists Fact Sheet. Other counties in PA can benefit from this resource: click here to download PA Wound Care Clinic Resource. Don’t hesitate to reach out to us.  Additionally, we offer a recorded webinar on Promoting Skin Integrity on our online Training Center.