Management of Pressure Injuries
Pressure injury management requires a systematic multidisciplinary approach centered on pressure relief, wound optimization, nutritional support, and addressing underlying barriers to healing, with early intervention critical to preventing progression and improving patient outcomes. 1, 2
Initial Assessment and Risk Stratification
Perform comprehensive pressure injury staging using the National Pressure Injury Advisory Panel classification system on admission and monitor skin integrity at least daily. 3, 4 Document wound size, depth, exudate characteristics, surrounding tissue condition, and evaluate for signs of local infection including increasing size, delayed healing, increased exudate, poor granulation, warmth, or malodor. 2
Conduct systematic risk assessment using validated scales (Braden, Norton, or Waterlow) at each clinical encounter, though recognize these tools have low sensitivity and specificity and clinical judgment may be equally effective. 3 Key risk factors to assess include: older age, black race or Hispanic ethnicity, lower body weight, cognitive impairment, physical impairments limiting mobility, comorbidities affecting tissue integrity, nutritional deficiencies (particularly hypoalbuminemia), and incontinence. 3
Core Management Principles
Pressure Relief and Repositioning
Implement regular repositioning every 2-4 hours based on individual risk assessment, adjusting frequency for higher-risk patients. 1 Use advanced static mattresses or overlays for patients at increased risk (strong recommendation, moderate-quality evidence), while avoiding alternating-air mattresses or overlays (weak recommendation, moderate-quality evidence). 3 Apply proper positioning, turning, and transferring techniques to minimize shear forces. 1
Wound Care Interventions
Clean wounds with gentle irrigation using normal saline or wound cleansers, avoiding antiseptic solutions that may damage healing tissue. 2 Apply appropriate dressings that maintain a moist wound environment while managing exudate, selecting advanced wound dressings based on wound characteristics (hydrocolloids for minimal exudate, foams for moderate to heavy exudate, or transparent films for superficial wounds). 2 Avoid both excessive moisture and dryness, as both impair healing. 2
For wounds requiring debridement, remove devitalized tissue and biofilm as necessary. 4 Monitor all injuries for local infection, biofilms, and osteomyelitis. 4
Nutritional Optimization
Ensure adequate protein intake of 1.25-1.5 g/kg/day and calories of 30-35 kcal/kg/day to support wound healing. 2 Consider protein supplementation for patients with nutritional deficiencies. 1 Ensure adequate hydration to support tissue perfusion and healing. 2
Moisture Management
Establish a standardized skin care protocol including adequate cleaning and hydration. 1 Use barrier ointments, liquid polymers, and cyanoacrylates to create a protective layer against moisture. 1 Address urinary or fecal incontinence to prevent wound contamination and further skin breakdown. 2 The pH changes from moisture-associated skin damage promote bacterial growth and impair wound healing, significantly increasing pressure injury risk when combined with pressure. 1
Management of Stage IV Injuries and Osteomyelitis
For Stage IV pressure injuries with pelvic osteomyelitis, surgical intervention may be necessary. 5 A 1-stage approach with bone debridement and flap coverage performed simultaneously or within 48 hours is adequate when there is no significant soft tissue infection, provided bone and tissue are adequately debrided and an appropriate flap is selected. 5 This approach shows similar healing rates to 2-stage procedures (delayed flap reconstruction at 4-6 weeks) while avoiding risks of bone desiccation. 5
Infection Management
Systemic antibiotics are not indicated for non-infected pressure injuries. 2 For suspected infection, obtain appropriate cultures using tissue samples or Levine technique swabs (not superficial swabs). 2 Initiate treatment with appropriate antibiotics based on culture results and local antimicrobial stewardship guidelines only when infection is confirmed. 2
Addressing Barriers to Care
Early engagement of social work and case management is essential to address psychosocial and socioeconomic barriers including depression, substance abuse, poor access to healthcare, unstable housing, and food insecurity. 5 Conduct psychiatric evaluation and management for mental health disorders and substance use. 5 Provide early pain management assessments to improve patient comfort. 5
Involve caregivers and legal guardians early in the care process, especially for patients with communication barriers. 5 Enroll patients and caregivers in institutional educational programs about pressure injury prevention and management. 5 Employ language support services to overcome communication barriers. 5
Implementation Strategies
Establish specialized pressure injury teams and develop standardized protocols to optimize management within the institution. 5 Create nurse-led multidisciplinary care teams to facilitate optimal guideline implementation. 3 Conduct regular pressure injury incidence audits to monitor program effectiveness. 3 Provide regular education and training updates for healthcare staff on evidence-based practices. 3
Use preventive dressings in high-risk areas, particularly in intensive care units and other high-acuity settings where patients face elevated risk. 1 Share successful case studies within healthcare teams to promote best practices. 3
Special Considerations and Monitoring
Address factors contributing to tissue hypoperfusion including diabetes control and smoking cessation. 2 Monitor for early signs of pressure injury development or progression. 1 Consider referral to a wound care specialist if the pressure injury fails to show improvement within 2 weeks of appropriate treatment. 2
Develop actionable care plans with regular follow-up to ensure consistent implementation. 3 Provide discharge planning and education for patients and caregivers to ensure continuity of care. 3
Common Pitfalls
Failure to recognize early moisture-associated skin damage can be avoided through regular, thorough skin assessments with particular attention to pH-balanced skin care products that maintain the skin's acid mantle. 1 Competing clinical priorities often lead to pressure injury prevention being deprioritized—address this through regular audits and education. 3 Limited access to appropriate support surfaces and skin care products requires proactive resource allocation. 3 High staff turnover necessitates continuous education and training to ensure consistent guideline implementation. 3