Pressure Injury

Posted by Nurse Linda in Life After Paralysis on October 28, 2020 # Health

This month’s blog has been dedicated to skin needs. The nemesis of individuals with decreased sensation is pressure injury (PI). The skin keeps our bodies safely contained and germs out. When there is pressure on an area of the skin, especially from the inside of the body, a pressure injury can occur. There are other wounds that can appear on the skin from poor circulation or skin diseases and rashes, but where there is a bone ending that digs into a muscle or other tissue without moving the body part to allow blood flow, a pressure injury develops.

People move and adjust their bodies thousands of times a day and night. When you have decreased or absent sensation, you may not recognize the need to move your body either consciously or subconsciously. The pressure injury starts inside the body as opposed to other skin injuries where there might be a tear in the skin that is the initiation of an event. Pressure injury occurs when a bone’s pointy ending, called a boney prominence, digs into the skin or muscle tissue from the inside of the body, creating enough pressure that blood cannot flow through the arteries, veins, or mostly, the capillaries. This starves the tissue of needed blood that carries oxygen and nutrients to feed the cells.stethoscope

Typically, pressure injury is classified in stages. Identification of the stage of a pressure injury can help healthcare providers communicate and establish the treatment needed to stop and clear the pressure injury.

Stage I: the discolored spot. A spot on your skin that is a different color than your normal tone is a pressure injury. In darkly pigmented individuals, this may appear as a darker spot, a purplish, or ashy spot. In lightly pigmented individuals, the spot may appear pink or red. For anyone, the spot may be very small, extremely large, or anywhere in between. Stage I is the dreaded ‘spot’ typically found where a bone end pushed against the tissues, impeding blood flow. The capillaries that are the closest to the surface of the skin do not have enough blood flow to move through them, which produces the spot. Either the blood flow has is insufficiently slowed or completely stopped.

Hopefully, you will discover this spot early through skin checks, even to areas that are not easily seen. If you cannot see your backside, feet, or any other areas, the use of a flexible long-handled mirror can help you see the nooks and crannies of your body. Another option is to take a photo of your personal cell phone. You will have a record from day to day, which will establish the start and progress of the spot.

Treatment of Stage I pressure injury is to stay off the area. If the spot is on your bottom where you sit, you cannot sit until the spot clears. If the spot is on your side, you cannot lay on that side; on your back, you might not be able to sit or lay on it. On the back of your head, you cannot lay on your back or put your head on your wheelchair headrest.

Once the spot resolves, you can start to put pressure on the spot again but very slowly. That means when the spot is completely gone, allow pressure for five minutes, then check your skin. If the spot is still not there, you can try ten minutes at the next session and so on until you reach your normal tolerance.

Most people fight these restrictions, and who could blame you. However, adherence to staying off the area keeps the spot from further pressure injury development. Once the PI moves to the next stages, there are increased consequences to your health and lifestyle. Staying off a ‘spot’ is inconvenient, but it is far less inconvenient than attempting to clear an open pressure injury.

Stage II: is the loss of the epidermis or top layer of skin with the dermis exposed. There may be a variable amount of drainage. The epidermis is a very thin layer of the top of the skin. It protects the dermis, which is under a layer of skin. The dermis contains blood vessels, nerve endings, oil glands, hair beds, among other tissues. The dermis does not have the protective qualities as the epidermis. An opening in the epidermis can allow bacteria and viruses to enter the body. Checking your skin may result in finding the ‘spot’ has already advanced.

Treatment of Stage II. The skin wants to heal right away to achieve its goal of protecting the body. A stage II pressure injury might heal relatively quickly, depending on the depth of the injury. It must be kept clean. A layer of ointment might be applied over the area. A sterile dressing will be needed. These are all techniques to keep the pressure injury from becoming infected.

The same pressure restrictions need to be followed as in any other wound. Not following the restrictions, even for a few seconds, will negate all the time you have spent off the area. This is because any pressure at all will re-damage the blood flow, each time making the circulation a bit harder to recover.

Stage III: Pressure injuries in this classification have the removal of both layers of skin. The injury is a pit in the fat of the body. These injuries are typically deeper in areas of the body where there is more fat. You may see tissue being naturally removed by the body inside the injury. This is called slough.

There could also be damaged tissue within the injury that looks sort of like a brownish scab of old blood, but thicker and deeper into the body. This tissue, called an eschar, is a combination of debris, old blood, and tissue. It should not be removed unless designated by a health professional as it is protecting something below it. Since it does provide some protection to the injury, it will eventually come out on its own when the area beneath it is ready for that to happen.

In these deep pressure injuries, it can be hard to see all aspects of the injury. Undermining (erosion) and tunneling can be affecting the structure of the tissue around the injury. Your healthcare professional will use a sterile cotton swab to probe the injury to locate undermining and tunneling.

Stage III pressure injuries will require packing (a sterile dressing placed inside the injury rather than on top) in the injury. The pressure injury should be packed with sterile dressing material, including packing into undermining and tunnel areas. This allows the injury to heal from the inside depth (granulation). Because the top layer of skin always will quickly close to protect your body, the skin should be held open by the packing. If the skin closes before the injury is completely healed, the injury area, including the undermining and tunnel(s), most likely will not yet be healed. The closed pressure injury will be unstable, reopening with pressure, or continue to expand under the closed skin. Infection can be present, which then creates an abscess within the body.

At stage III, the skin edges of the pressure injury might begin to curl under. This is called epibole. The epidermis tends to roll into the injury over the dermis layer because it is trying to close the injury opening. Once this occurs, the epidermis feels it has done its job and stops trying to grow over the injury opening. To stop this from happening, the pressure injury should be packed fully to the top. If epibole does occur, it can be debrided with chemicals or with a scalpel by your healthcare professional.

Restrictions to stay completely off the area needs to be maintained. These injuries take time to heal. Maintaining no pressure on the area is a commitment but still less time for healing than allowing the injury to continue to progress due to added pressure.

Stage IV: Includes both layers of skin, tissue, fascia, muscle, tendon, ligament, cartilage, and perhaps bone. The crater of the injury may also contain slough and/or eschar. The skin can develop the epibole edge. Undermining and tunneling are likely to be present. As with all pressure injuries, the possibility of infection is present, but because more body tissues and bone are involved, the risk of infection is even greater.

Packing these injuries will be necessary to ensure the injury heals from the bottom of the area before the top layer of skin closes. These pressure injuries follow the same treatments and restrictions to stay off the area. Healing these injuries take extensive periods of time, yet still less than continuing with adding additional pressure on the area.

Unstageable: Pressure injuries that cannot be examined because they are enclosed in eschar are termed unstageable. Keeping off the area is the primary treatment. The injury should remain closed if eschar is stable without swelling or if on a limb with poor circulation. An MRI or CT may be done to see the condition of the injury internally, especially if it has entered the bone. The results of the scan will indicate the treatment required. No pressure should be placed on the area.

Deep Pressure Injury: If the discolored area of your skin is especially dark, you may have a deep pressure injury. This is most often a shearing injury resulting from pressure and friction. It can quickly deteriorate into a Stage III or Stage IV injury. No pressure should be allowed in the area.

Healing a Pressure Injury

The number one step in healing a pressure injury is to remain completely off the area. Each time you sit, lay, poke, message, or put any pressure on the pressure injury area, you are constricting blood flow. The blood vessels, including those tiny capillaries, need time to heal, which will reinvigorate blood flow. Even just a brief time of pressure can undo your efforts of remaining off the area. If the vessels have a tiny amount of healing and pressure is re-added, they collapse again with increasing trauma each time. PI caught early is much easier to heal. It can be very disappointing not to be able to enjoy your life’s routines. This is an unfortunate but necessary consequence.

Frequent pressure releases are key to avoiding pressure injury. There is no other action that works to allow blood flow through the vessels and capillaries. Find a trigger in the environment that will remind you to release pressure or use an alarm. You must release the pressure every 15 minutes for 2 minutes when up and turn in bed every two hours. The use of pressure dispersing equipment benefits you but cannot eliminate pressure.

Check your pressure dispersing equipment, bed surface, seating surfaces, headrests, as well as adaptive equipment to make sure it is performing to your needs. Pressure mapping can be done by the physical therapist to ensure your equipment is right for you. Inefficient equipment should be fixed or replaced. Pressure dispersing equipment does not eliminate pressure. You still need to do pressure releases.

Perform skin checks regularly. Spotting and staying off that first change in pigmentation can save a lot of woes later. Once a pressure injury has occurred, the skin is less elastic, which means it won’t have that bit of ‘give’ and flexibility. An area of skin that has been affected by PI is more susceptible to future breakdowns.

Review your transferring skills. You may need additional therapy or transferring equipment to move or having someone move you.

Assess your diet for health. Good nutrition will help feed your cells, making them healthy. Ask for a consultation with a dietician who can calculate the correct number of calories (or energy), protein, micronutrients (zinc, vitamin C, vitamin A, and iron), and fluids for you. Restrictions may apply for fluids due to bladder programs. Getting enough nutrition is key when you might feel full due to a slow bowel or increased energy needs due to tone (spasms).

All pressure injuries take a great deal of time to heal, especially the Stage III and Stage IV injuries. A good course of action is to follow the dressing change process carefully and to stay off the area. Stage III and Stage IV injuries may require the use of a wound vacuum to control drainage and to provide constant light suction to clean debris from the pressure injury.

Surgical repair of pressure injury is a serious undertaking. The skin and muscle must be rearranged. Bones might need to be reduced. Staying off the surgical site is mandatory for healing. It is not uncommon to be bedfast for at least six months but more likely for over a year. That is quite a loss of time. Staying off an area for a day or a few weeks when there is just a spot is far less restrictive.

While you are recovering from a pressure injury, remember to exercise your body. Doing a range of motion exercises to every limb and joint will help to keep your body in shape for a return to your activities and life. Nurse Linda

Pediatric Consideration: Skincare is often overlooked in children because their skin is so healthy and elastic. However, pressure injury can happen in adult bodies. From the moment of a medical condition or trauma, skin checks should be performed. While you do the skin check, tell your child what you are doing. Have them look with you. This develops a habit.

Education of children in skincare can become an integral part of their being. If they know what to do, they can tell caregivers as they get older. Children love to have a responsibility, so why not make it something that is critically important to them without adding the consequences until they are developmentally ready.

Be sure you use pressure dispersing equipment that is the right configuration for the age of your child plus about five years. New equipment needs to be able to grow with your child and still be appropriate. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.