What is the treatment plan for a pressure injury?

Treatment Plan for Pressure Injuries

The treatment of pressure injuries requires a multidisciplinary approach focusing on wound care, nutritional support, and pressure redistribution, with specific interventions tailored to the injury stage. 1

Assessment and Classification

• Pressure injuries are classified into four stages based on depth of tissue damage:

  • Stage 1: Non-blanchable erythema of intact skin
  • Stage 2: Partial-thickness skin loss with exposed dermis
  • Stage 3: Full-thickness tissue loss exposing subcutaneous fat
  • Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle 1

• Document size, location, and characteristics of the wound including:

  • Wound dimensions (length, width, depth)
  • Presence of undermining or tunneling
  • Wound bed characteristics (granulation, slough, necrotic tissue)
  • Exudate amount and characteristics
  • Signs of infection 1

Treatment Algorithm by Stage

Stage 1-2 Pressure Injuries

1. Wound cleansing:

   • Clean with normal saline solution
   • Avoid antiseptics that may damage granulation tissue 2

2. Dressing selection:

   • Use hydrocolloid or foam dressings to reduce wound size (weak recommendation, low-quality evidence) 3
   • For stage 2 injuries with light to moderate exudate, hydrocolloid dressings are recommended
   • Change dressings according to manufacturer recommendations and exudate levels 1

3. Pressure redistribution:

   • Implement turning schedule every 2 hours
   • Use specialized support surfaces (air-fluidized beds have moderate-quality evidence for reducing ulcer size) 3, 1

Stage 3-4 Pressure Injuries

1. Debridement:

   • Remove necrotic tissue and biofilm
   • Methods include sharp debridement (preferred for extensive necrosis), enzymatic, or mechanical debridement 1, 2
   • Prompt debridement is essential for infected wounds 2

2. Wound management:

   • For moderate to heavy exudate: Use alginate or hydrofiber dressings
   • Consider antimicrobial dressings if signs of local infection or biofilm are present 1
   • Electrical stimulation may accelerate wound healing as adjunctive therapy (moderate-quality evidence) 3

3. Infection management:

   • Monitor for signs of local infection (increased pain, erythema, edema, purulent drainage, malodor)
   • Assess for biofilm formation (delayed healing despite care, poor granulation)
   • Evaluate for osteomyelitis in stage 4 injuries (prevalence 17-58%) 1
   • Systemic antibiotics only when clear evidence of infection exists 1, 4

4. Surgical consultation:

   • Consider if wound fails to improve with conservative management
   • Appropriate for stage 4 injuries with bone exposure or extensive undermining 1

Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size (weak recommendation, low-quality evidence) 3
• Ensure dietary intake of 30-35 kcal/kg/day and 1.25-1.5 g protein/kg/day 1
• Supplement micronutrients that enhance wound healing (vitamin B6, B12, folate, zinc, vitamin C, vitamin D) 1
• Maintain adequate hydration 1

Monitoring and Follow-up

• Regularly reassess wound characteristics to evaluate healing progress
• Document changes in wound size, depth, and appearance
• Adjust treatment plan if healing is not progressing as expected
• Continue pressure redistribution measures even after healing 1

Common Pitfalls to Avoid

• Misclassifying darkly pigmented skin where erythema may be difficult to detect
• Using inappropriate dressings for wound type and exudate level
• Failing to address nutritional deficiencies
• Overusing antibiotics without clear evidence of infection
• Inadequate pressure redistribution 1
• Neglecting to evaluate for biofilm formation, especially in stages 3 and 4 1

By following this structured approach to pressure injury management, clinicians can optimize wound healing, reduce complications, and improve patient outcomes.