​Thinking Differently about Pressure Injury Treatment Part 2

Posted by Nurse Linda in Life After Paralysis on June 09, 2022 # Health

doctorOnce a pressure injury has appeared, you need to take immediate action. Contact your health professional for all pressure injuries regardless of the stage. You may be referred to a wound care specialist to help heal your wound. Do not be embarrassed as you know pressure injuries develop for a variety of reasons, many of which do NOT include lack of care on your part. A pressure injury usually occurs due to combinations of reasons that can include self-care issues but also metabolic reasons.

You need to be evaluated for treatment. If the wound is open, a treatment plan will be made for you to follow. If you see a change in pigmentation without an opening in the skin that you have dealt with previously, you may already know your plan. You will need to work with your healthcare professional if an area is repeating pressure injuries. Corrections to equipment and devices may need to be taken. Regardless of the cause, stay off the area completely.

When a pressure injury occurs, take a private photo with your personal camera to track progress regardless of the stage. Include a ruler near the wound to note the exact size. Paper ruler tapes are softer protection for the skin. The date and time of the photo will be recorded on your camera. If you print the photo, you may need to add the date. You can take photos daily or every few days to record your progress.

When you see your healthcare provider, the wound will be given a stage. Treatment has variabilities depending on the stage. All pressure injuries require removing pressure from the area of the wound. That means staying off the area completely, not adding pressure just for a few minutes. This will negate all your effort in staying off the wound. It means in bed if the wound is in a sitting area or not turning on that side when in bed. Do not push on the wound to check blood flow. Do not message the wound or area surrounding it. No pressure, period.

Stage I wounds are changes in pigment. Staying off the area is required. If caught early, this may be for a few hours or days. Some wounds, even just pigment changes, may take longer to resolve because the skin surface change is just a small indicator of the wound that is inside the body, which you cannot see. If the pigment changes, you stay off the area. If the change in pigment resolves but returns when pressure is reapplied, the internal damage has not yet healed.

It will take time to rebuild your skin tolerance. Restarting skin pressure tolerance means allowing pressure for 5 to 10 minutes, then checking for pigment changes. If pigment changes return, you need more time off the area. If no pigment change occurs, you can try 10 to 15 minutes, waiting at least two hours from your first attempt, and so on. If you had a pigment change, you cannot just go back to your original sitting or lying tolerance as before due to the unseen internal issues. Rebuilding skin tolerance must be done to prevent more injury.

Stage 2-4 and unstageable are open areas on the skin surface and into the tissue below. In Stage 2, the surface of the skin is open; therefore, a covering should be applied to prevent bacteria from entering the body. Stage 2 may also have a bit of drainage, which needs to be contained. Because the top layer or layers is off the surface of the skin, any clothing or dry dressing can stick to the wound. Without a dressing, when garments are removed, so is any healing skin. Stage 3-5 and unstageable wounds need to be kept moist and clean, typically by use of normal saline. An electrolyte balanced sterile solution. Water is not electrolyte balanced, which draws fluids out of the cells, interrupting healing. Of course, you must stay completely off any type of pressure injury.

Commonly used wound dressings include dressings with a water-based gel, foam dressings, hydrocolloid (moist environment that lets the body heal itself) dressings, or alginate (biodegradable made from seaweed) dressings. The amount of wound drainage plus multiple other factors will determine what type of dressing is used. There are many types of dressings, and your healthcare professional will choose the one that is right for you.

Packing or placing a dressing within the wound is used if the wound is deep, thereby getting treatment to the bed or bottom of the wound. This may include packing tunnels or fistulas (small offshoots of the wound further into the body. Packing can be used to ensure the wound heals from the bed or base of the wound. The skin will be apt to close first because it needs to defend the body. However, in the case of pressure injuries, the wound must heal from the bed. Packing can help keep the skin open until the bed of the wound has healed. If the skin closes too soon and the bed is still healing, a pocket can form that encloses infection, which will take the path of least resistance. The wound fluid, pus, or bacteria will not be able to leave through the skin but can spread to the soft tissue within the body.

Open wounds may need treatments to avoid infection or treat infection because there is an opening in the skin, the body's first defense against infection. Antibiotics may be needed to apply to the wound or taken by mouth to avoid a system (body) infection. If there is no infection, antibiotics are not used.

Stage 3 and 4 and unstageable wounds may need to have some removal of debris in the wound. Normally, this debris protects the wound from infection, but the debris can be the infection. Your healthcare professional will direct you if this substance needs to be left alone or sequentially removed in small amounts over time.

There are several ways to debride or remove the debris. Wet-to-dry dressings are commonly used by moistening a gauze with normal saline, packing it into the wound, and removing it when the packing is somewhat dry. The wound debris adheres to the dressing and comes out when the dressing is removed. Some debris is removed with enzyme creams, ointments for the process, or medical honey. Medical honey is not from your neighbor’s beehive but purified, sterile, and treated honey that removes debris. It is not eaten but applied to the wound.

Wound vac therapy is a vacuum that is applied to your wound. It creates a negative pressure on the area of the wound to speed healing. The gentle pressure helps remove debris, excess fluid, and bacteria. It may stimulate the growth of healing tissue. In this treatment, the wound is completely sealed off with a dressing. A specialized vacuum that is set for gentle pressure is attached. This will stay in place for several days. A vacuum pump goes where you go as it is portable. Some individuals do not care for the noise the pump makes. Not everyone is a candidate for this therapy. For those recommended, it is a comfortable and usually successful treatment.

More advanced treatments to clean debris from wounds include irrigation of the wound with a power sprayer, much like a dental water pick to remove debris. Too much pressure can destroy healthy tissue, so knowledge of this treatment must be undertaken. Other debridement therapies include ultrasound sessions, laser use, surgery, and even biosurgery (use of maggots). Hyperbaric treatments are also used.

Chronic pressure injuries are those at a higher stage, not healing even with proper care, or are very large. Surgical repair of pressure injuries is performed in these cases. This is a major commitment on the part of the individual. In the surgery, the pressure injury is cleaned, muscle is usually moved to add protection to the boney prominence, and a flap of viable skin is rotated over the area to close it. This is a big surgery. A commitment from the individual to stick to a recovery plan must be given to have the surgery performed. Typically, an individual will have to stay in bed, off the surgical area, for a period of six to nine months to ensure healing. Yes, that is a long commitment. However, it takes that long for all the internal reconfigurations to heal. After the individual can get up, the process of rebuilding skin tolerance restarts for just five minutes of sitting up, as indicated above. It takes a very long time to rebuild sitting tolerance. Putting pressure on the surgical wound too soon will destroy your efforts and the surgical site.

Treatment of a pressure injury is easiest when caught early. Usually, a scar has not developed on the surface of the skin. A scar is not elastic like natural skin. Scars have no stretch, so areas with scars are more prone to recurring pressure injury. Treating a pressure injury early to avoid scarring and to avoid surgery (which leaves a huge scar from the flap rotation). People tell me staying off the wound for a few days or a month is inconvenient. However, requiring further treatments just make this time longer. Treat pressure injury early. Nurse Linda

Pediatric Consideration:

Children are naturally busy people. They have a lot of things to see and play to do. Keeping a child off a pressure injury is a challenge but one that must be met to avoid further damage. A pressure injury area, especially one with a scar, can be fragile for the rest of their lives, so prevention and early treatment are key.

Alternatives for school are essential. Some schools will allow the child to participate in class in a reclined position with a turning schedule eliminating the side with the pressure injury, but this is generally not an option for mainstream schools. Homeschooling may be needed, which disrupts the child’s life as well as the parents. Again, early prevention is necessary as the consequences ripple throughout the family. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

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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.