Pressure injury

Pressure ulcers are common in people confined to bed for long periods, or immobilised due to a disease/accident. Each year in France, 300,000 patients are risk of developing a pressure ulcer (1). It is a wound which requires frequent care, which can take several months to heal and which mainly affects elderly patients (74 years on average).

What is a pressure injury?

A pressure injury is a chronic wound which appears when sitting or lying for a prolonged period, which creates pressure in the weight-bearing areas. This pressure compresses the tissue between two hard surfaces. This prevents the blood from flowing normally leading to reduced oxygen supply, which causes damage to the tissue and a wound can eventually develop within just a few hours.

In 80% of cases, a pressure injury appears on the sacrum, on the heel and patients that have prolonged areas of weight-bearing (such as reduced mobility and disable patients). These wounds can also occur on the elbows, shoulder blades, or the back of the head.

Defined by NPIAP, pressure injuries are classified by stage according to their severity.

  • Stage 1 : Persistent redness. Stage 1 pressure injury is redness which appears and which does not disappear when pressed. . The skin is not yet broken, and there is not yet a wound. Specific treatment must be started at this stage. In this case it is recommended to not massage the area as this may aggravate the condition.
  • Stage 2 : Erosion of the skin of the epidermis and the dermis. The wound is formed and the skin is broken.
  • Stage 3 : The epidermis, the dermis and the hypodermis are affected. There is necrotic (black) tissue and scabs. NB: the pressure injury always appears smaller on the surface than it is deeper down.
  • Stage 4 : Deep pressure injury. Deep necrosis with possible involvement of the bones, tendons and muscles.

Factors promoting the appearance of pressure injuries:

  • Immobility
  • Patient age. Even if pressure ulcers can also occur in children, patients over the age of 70 are especially at risk.
  • Malnutrition
  • The quality of the skin. The finer it is, the more sensitivities to friction, to shear, stress and to pressure.
  • Incontinence, which causes permanent humidity and renders the tissue or fragile due to maceration.
  • Impaired motricity and lack of mobilisation
  • Sensitivity. Patients may have loss of sensation and are unable to change position.

Pressure injury treatment

Regardless of the stage of the pressure ulcer, treatment must be started as soon as possible.

The type of treatment depends on the stage of the pressure ulcer.

If the skin is broken (stages 2 and above) appropriate wound cleansing and dressing treatment should be support by the nursing staff.

Regardless of the severity of pressure injury first thing to do is to remove pressure. Patients position should be changed every 2 to 3 hours. Setting up a specialised bed, specific mattress (foam, water, air) and cushions, will relieve and distribute pressure in the high-risk areas. Treatment should come with appropriate nutritional management and management of the various comorbidities.

And afterwards?

When we know that two hours without moving is enough to create a pressure ulcer the following prevention measures will be just as useful to the patient as to their carers:

  • Always examine the areas of the body in which a pressure injury is likely to develop (weight-bearing areas).
  • Move the patient, even if it means calling on a nurse or physiotherapist.
  • Fully wash the patient at least once a day and clean the perineal area each time the patient goes to the toilet.
  • Avoid using rough fabric to dry the skin.  
  • Change sheets daily.
(1) Quoted by C. Revaux in the Consensus Conference Prevention and Treatment of Pressure Ulcers in Adults and the Elderly (Conférence de consensus Prévention et traitement des escarres de l’adulte et du sujet âgé). 15/16 Nov 2001. Georges Pompidou European hospital