Pressure ulcers are classified into stages based on tissue involvement, per the National Pressure Injury Advisory Panel (NPIAP):

1. Stage 1: Non-blanchable erythema of intact skin; may be painful or warm.

2. Stage 2: Partial-thickness skin loss with exposed dermis; presents as a shallow ulcer or blister.

3. Stage 3: Full-thickness skin loss involving subcutaneous tissue; may include undermining or tunneling.

4. Stage 4: Full-thickness loss extending to muscle, bone, or tendons; often includes necrosis.

5. Unstageable: Obscured by slough or eschar, requiring debridement to determine depth.

6. Deep Tissue Injury: Persistent discoloration (purple/maroon) with intact or broken skin, indicating underlying tissue damage.

Prevention Strategies

Preventing pressure ulcers is a priority, guided by evidence-based practices:

1. Risk Assessment: Use tools like the Braden Scale to evaluate risk factors (mobility, nutrition, moisture, sensory perception).

2. Repositioning: Turn immobile patients every 2 hours, using 30-degree lateral tilts to offload pressure points (e.g., sacrum, heels).

3. Support Surfaces: Utilize pressure-relieving devices (e.g., foam mattresses, air overlays) for high-risk patients.

4. Skin Care: Keep skin clean and dry, apply moisturizers for dryness, and use barrier creams for incontinence.

5. Nutrition: Ensure adequate protein, calories, and hydration to support tissue repair; consult dietitians for deficiencies.

6. Patient Education: Teach patients and families about repositioning and skin inspection to promote self-care.

Treatment Approaches

Treatment varies by stage and requires a multidisciplinary approach:

• Stage 1:

  • Relieve pressure using repositioning schedules and support surfaces.

  • Apply transparent films or hydrocolloid dressings to protect skin.

  • Monitor daily for progression.

• Stage 2:

  • Cleanse with saline; avoid harsh antiseptics.

  • Use hydrocolloid or foam dressings to maintain a moist healing environment.

  • Reassess frequently for infection or worsening.

• Stage 3/4:

  • Debride necrotic tissue (e.g., enzymatic or surgical debridement) in collaboration with wound care specialists.

  • Apply advanced dressings (e.g., alginate for exudate, silver dressings for infection).

  • Consider negative pressure wound therapy for large wounds.

• Unstageable/Deep Tissue Injury:

  • Consult specialists for debridement and staging.

  • Protect surrounding tissue with appropriate dressings.

• Infection Management:

  • Assess for signs (e.g., foul odor, increased exudate); obtain wound cultures if indicated.

  • Administer prescribed antibiotics and maintain aseptic technique during dressing changes.

Nursing Responsibilities

Nurses play a pivotal role in pressure ulcer care through:

• Assessment: Inspect skin daily, focusing on bony prominences (e.g., heels, sacrum); document stage, size, and wound characteristics.

• Documentation: Record interventions, wound progress, and risk scores in the patient chart for continuity of care.

• Implementation: Perform dressing changes using aseptic technique, reposition patients, and apply prescribed treatments.

• Collaboration: Work with wound care nurses, dietitians, and physical therapists to optimize outcomes.

• Patient Education: Teach patients and caregivers about prevention strategies, such as proper positioning and nutrition.

• Advocacy: Ensure access to pressure-relieving devices and report barriers (e.g., inadequate staffing) to management.

Challenges in Pressure Ulcer Care

Obstacles include:

• Patient Factors: Non-compliance with repositioning due to pain or cognitive impairment.

• Resource Limitations: Lack of specialized mattresses or dressings in low-resource settings.

• Time Constraints: High workloads may delay assessments or interventions.

• Complexity: Managing advanced ulcers requires specialized knowledge and coordination.

Mitigation involves prioritizing high-risk patients, leveraging team support, and seeking continuing education on wound care.

Integration into Nursing Practice

Pressure ulcer care aligns with the nursing process:

• Assessment: Evaluate skin and risk factors.

• Diagnosis: Identify “Impaired Skin Integrity” or “Risk for Pressure Ulcer.”

• Planning: Develop a care plan with repositioning and dressing schedules.

• Implementation: Execute prevention and treatment strategies.

• Evaluation: Monitor wound healing and adjust interventions as needed.