Pressure injuries are changes in the skin seen in people who are generally immobile (e.g. after CVA or spinal injury) or are unable to mobilise themselves in a normal manner (e.g. following surgery). Usually, when someone is sitting or lying in the same position for too long, pressure is relieved by changing position, or perhaps even getting up and going for walk. This takes away the discomfort, and also ensures that the blood supply to that part of the skin is returned to normal.
Where the skin passes over a bony prominence (e.g. the heels, elbows and hips) it is often quite thin, and this means that any skin trapped between the bone and the support surface will be more likely to be damaged faster than normal skin. The skin is also naturally thinner in the older person. When an older person becomes ill their food intake decreases and they also become much less mobile.
Add to this the possibility that they may become incontinent, and all the factors are present which, if left untreated, may lead to the development of a pressure injury (see Pressure Injury Identification Guide). Such wounds can result in considerable patient distress, as they can be very painful, and in severe cases may lead to infection, and even septicaemia and death. It should be stressed, however, that pressure injuries are not confined to the elderly, and that anyone who is immobile for any length of time is susceptible to pressure injury.
According to the most recent guidelines, the prevalence of pressure injury in Australia ranges from 5.6% to 48.4% in acute and sub-acute healthcare facilities, while in Australian long term care facilities it was estimated in 2004 to be 26%. The most recent prevalence rates in New Zealand were 29% in an acute care facility, and 38.5% in an intensive care unit of a major teaching hospital.1
So how should clinicians approach this problem? Firstly, by ensuring there is a procedure in place to identify those patients who are at risk of developing pressure injuries. There are many published pressure injury risk assessment scales available (e.g. Braden2) which are simple to use and can be easily implemented in most units. All patients, without exception, should be assessed on admission, and every time their condition changes.
Secondly, every facility should have in place a management protocol designed to prevent the development of the injury. This will have a number of components including: provision of pressure relieving support surfaces, which may include using dermal gel pads placed under the heels and/or sacrum (e.g. DERMAPAD?)3; adequate nutritional support; ensuing that skin remains supple through washing with pH neutral products and adequate moisturising; prevention of damage from incontinence with use of barrier creams (e.g. the SECURA? skin care range) and perhaps catheterisation; mobilisation wherever possible; and frequent repositioning. Guidance on all of these interventions can be found in the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury.1
Sometimes, despite all the best efforts a pressure injury still occurs. When this happens, ensuring the best possible wound care is the priority. This will include adequate debridement and the provision of a dressing that promotes moist wound healing, in addition to the removal of all pressure.
It is also worth remembering that although a high pressure will result in damage over a relatively short period of time, low pressure is equally damaging if applied over a long time. Because of this it is important to remember that good pressure injury prevention does not include sitting in a chair all day: in fact this is one of the most common causes of injury.
DERMAPAD – How it works.
High pressure points can disrupt the flow of blood and the supply of oxygen which can cause damage to the skin. DERMAPAD works by helping to redistribute pressure over a larger area to reduce the peak pressure at any one point by up to 89% (in-vitro)4
This article is sponsored by Smith & Nephew Pty Ltd.
1. Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Osborne Park: Cambridge Media; 2012.
2. Bergstrom, N. et al. The Braden Scale for predicting pressure sore risk. Nursing Research 1987; 36: 205-210.
3. Woods S. Aderma+ dermal pads in the prevention of pressure ulcers. Wounds UK 2012; 8(4): 148-151.
4. Grayson N. ADERMA Pressure Mapping Assessment (9in-vitro). Data on file; 2012: report CCA2109/R2b.
+ In Australia, ADERMA is marketed as DERMAPAD
? Trademark of Smith & Nephew © Smith & Nephew 2014
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