Pressure injury and staging
Pressure injury
- Localized damage to the skin and underlying soft tissue
usually over a bony prominence or related to a medical or
other device
- Occurs as a result of intense and or prolonged pressure or
pressure in combination with shear
- Can be affected by microclimate, nutrition, perfusion, co
morbidities and condition of the soft tissue
Pressure
- Force exerted perpendicular to the skin surface
- Damages the skin and underlying tissues by directly
deforming and damaging tissue
- OR compressing small blood vessels hindering blood flow and nutrient supple
- Through ischemia – reperfusion injury
- When pressure Is redistributed over a greater surface area the pressure is less intense in any
one area
Shear
- The force exerted parallel to the tissue
- Actual distortion or deformation of tissue as a result of shear stress
- Can be intensified by raising the head of the bed higher than 30 degrees, dragging instead of
lifting
- One layer of tissue slides over another deforming adipose and muscle tissue and disrupting
blood flow
STAGE 1
- Intact skin with a localized area of non blanchable erythema
- Presence of blanchable erythema or changes in sensation, temp, or firmness ma precede
visual changes may precede visual changes
STAGE 2
- Partial thickness loss with exposed dermis
- Wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum
filled blister
- Adipose is not visible
- Slough not present
STAGE 3
- Full thickness loss of skin in which adipose is visible in the ulcer and granulation tissue
- Slough and or eschar may be visible
- Undermining and tunneling may occur
- Fascia, muscle, tendon, ligament, cartilage or bone is not exposed.
- If slough obscures the extent of tissue loss this is an unstageable pressure injury
STAGE 4
- Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer
- Slough may be visible, undermining and tunneling often occur
UNSTAGEABLE PRESSURE INJURY: OBSCURED FULL THICKNESS SKIN AND TISSUE LOSS
- Full thickness skin and tissue loss in which the extent of tissue damage which the ulcer cannot
be confirmed because it is obscured by slough
, DEEP TISSUE PRESSURE INJURY (DTPI)
- Intact of nonintact skin with localized area of persistent non blanchable deep red, or purple
- 9-12% of pressure injuries
- Patients are usually older, sicker, and more likely to be hospitalized
MUCOSAL MEMBRANE PRESSURE INJURIES
- Areas like lips and nares
- History of a medical device in use at the locations of the injury
- Can not be staged
COMMON LOCATIONS
- Ear, Scapula, Spinous process, Shoulder, Elbow, Iliac crest, Sacrum/coccyx, Ischial tuberosity,
Trochanter, Knee, Malleolus, Heel, Toe
Pressure injury Healing
- Proliferation Phase: new tissue forms and the wound contracts
o Angiogenesis
Formation of new capillaries to restore the vascular system\
o Granulation
Fibroblasts migrate into the wound and produce new collagen and other extra-
cellular matrix substances
This tissue is highly vascular because of angiogenesis. It appears as beefy red
tissue in the wound bed.
o Epithelialization
Epithelial cells migrate from the wound edge. Epithelial stem cells also migrate
from any hair follicles that remain in the wound bed.
Appears clinically along the wound edge as tissue that is thin, pearly, or silvery
and shiny
Newly epithelialized wound tissue appears pink/paler pink
o Wound contraction
Collagen fibers and extra-cellular matrix contract
Seen clinically as a reduction in wound depth and size
- Maturation/Remodeling Phase - scar tissue is remodeled and strengthened.
o Scar tissue mass and vascularity diminish
o This is seen clinically as the shrinking and thinning of the scar and change in scar tissue
appearance from red or pink to nearly the same color as the surrounding skin or silvery
white
o In darker skinned individuals, mature scar tissue may appear as an area of
hypopigmentation
o The maturation/remodeling phase may last for one year or longer. However, scar tissue
strength remains less than that of normal tissue.
o The decline in tensile strength increases the risk for re-injury
ARTERIAL ULCERS
- Impaired arterial blood flow to the lower leg and foot
- Results in tissue, ischemia, necrosis, and loss
- Causes
o Most commonly – Atherosclerosis
o Arteriosclerosis
o History of arterial insufficiency to lower extremities:
Pressure injury
- Localized damage to the skin and underlying soft tissue
usually over a bony prominence or related to a medical or
other device
- Occurs as a result of intense and or prolonged pressure or
pressure in combination with shear
- Can be affected by microclimate, nutrition, perfusion, co
morbidities and condition of the soft tissue
Pressure
- Force exerted perpendicular to the skin surface
- Damages the skin and underlying tissues by directly
deforming and damaging tissue
- OR compressing small blood vessels hindering blood flow and nutrient supple
- Through ischemia – reperfusion injury
- When pressure Is redistributed over a greater surface area the pressure is less intense in any
one area
Shear
- The force exerted parallel to the tissue
- Actual distortion or deformation of tissue as a result of shear stress
- Can be intensified by raising the head of the bed higher than 30 degrees, dragging instead of
lifting
- One layer of tissue slides over another deforming adipose and muscle tissue and disrupting
blood flow
STAGE 1
- Intact skin with a localized area of non blanchable erythema
- Presence of blanchable erythema or changes in sensation, temp, or firmness ma precede
visual changes may precede visual changes
STAGE 2
- Partial thickness loss with exposed dermis
- Wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum
filled blister
- Adipose is not visible
- Slough not present
STAGE 3
- Full thickness loss of skin in which adipose is visible in the ulcer and granulation tissue
- Slough and or eschar may be visible
- Undermining and tunneling may occur
- Fascia, muscle, tendon, ligament, cartilage or bone is not exposed.
- If slough obscures the extent of tissue loss this is an unstageable pressure injury
STAGE 4
- Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer
- Slough may be visible, undermining and tunneling often occur
UNSTAGEABLE PRESSURE INJURY: OBSCURED FULL THICKNESS SKIN AND TISSUE LOSS
- Full thickness skin and tissue loss in which the extent of tissue damage which the ulcer cannot
be confirmed because it is obscured by slough
, DEEP TISSUE PRESSURE INJURY (DTPI)
- Intact of nonintact skin with localized area of persistent non blanchable deep red, or purple
- 9-12% of pressure injuries
- Patients are usually older, sicker, and more likely to be hospitalized
MUCOSAL MEMBRANE PRESSURE INJURIES
- Areas like lips and nares
- History of a medical device in use at the locations of the injury
- Can not be staged
COMMON LOCATIONS
- Ear, Scapula, Spinous process, Shoulder, Elbow, Iliac crest, Sacrum/coccyx, Ischial tuberosity,
Trochanter, Knee, Malleolus, Heel, Toe
Pressure injury Healing
- Proliferation Phase: new tissue forms and the wound contracts
o Angiogenesis
Formation of new capillaries to restore the vascular system\
o Granulation
Fibroblasts migrate into the wound and produce new collagen and other extra-
cellular matrix substances
This tissue is highly vascular because of angiogenesis. It appears as beefy red
tissue in the wound bed.
o Epithelialization
Epithelial cells migrate from the wound edge. Epithelial stem cells also migrate
from any hair follicles that remain in the wound bed.
Appears clinically along the wound edge as tissue that is thin, pearly, or silvery
and shiny
Newly epithelialized wound tissue appears pink/paler pink
o Wound contraction
Collagen fibers and extra-cellular matrix contract
Seen clinically as a reduction in wound depth and size
- Maturation/Remodeling Phase - scar tissue is remodeled and strengthened.
o Scar tissue mass and vascularity diminish
o This is seen clinically as the shrinking and thinning of the scar and change in scar tissue
appearance from red or pink to nearly the same color as the surrounding skin or silvery
white
o In darker skinned individuals, mature scar tissue may appear as an area of
hypopigmentation
o The maturation/remodeling phase may last for one year or longer. However, scar tissue
strength remains less than that of normal tissue.
o The decline in tensile strength increases the risk for re-injury
ARTERIAL ULCERS
- Impaired arterial blood flow to the lower leg and foot
- Results in tissue, ischemia, necrosis, and loss
- Causes
o Most commonly – Atherosclerosis
o Arteriosclerosis
o History of arterial insufficiency to lower extremities:
