Pressure Injuries: Prevention and Treatment

Topic Overview

How can pressure injuries be prevented?

Relieve pressure on the skin

Relieving and spreading out pressure is the most important part of both preventing and treating pressure injuries. Putting pressure on one spot for long periods of time decreases blood flow to that area. This damages or kills the cells and creates a sore. Pressure can be relieved and spread in several ways. Often a combination of these is best.

To relieve and spread pressure:

• Change positions at least every 2 hours if you are confined to a bed. Change as often as every 15 minutes if you are in a wheelchair.
• Avoid sliding, slipping, or slumping, or being in positions that put pressure directly on an existing pressure injury. Try to keep the head of a bed, a recliner chair, or a reclining wheelchair raised no more than 30 degrees. Recliner chairs are likely to allow slipping. They should not be used in place of a bed.
• Use special support surfaces. There are mattresses, bed covers, and chair cushions designed to help reduce and spread pressure. Other products, such as doughnut-type devices, may actually cause pressure injuries. Talk with your doctor about which products would be best for you and where to buy them.
• Work with your doctor to be sure there is either no pressure on your skin or that there is good padding between your skin and other surfaces.

Protect your skin

Take good care of your skin.

• Bathe as often as needed to be clean and comfortable. Use gentle soap, and use warm (not hot) water. Be careful not to scrub the skin too hard.
• Use moisturizing creams or lotions to keep skin soft and keep it from getting too dry. Dry skin is more easily damaged.
• If you have problems with bowel or bladder control, clean your skin right away if it becomes soiled or wet. Use a protective barrier cream, lotion, or ointment to protect your skin from wetness. Use pads or briefs that absorb moisture and pull it away from your skin.
• Check your skin every day for signs of pressure injuries. Pay special attention to bony areas such as the hips, elbows, knees, and heels. Also watch for pressure from sources such as:
  • Body parts or skin folds, especially if you're overweight. For example, the knees or ankles may rub together and cause sores.
  • Chair arms, parts of wheelchairs, braces, or other places where you rest your elbows or other body parts.
  • Medical equipment such as oxygen masks or oxygen tubing.

Good health habits can also help protect your skin.

• Eat a healthy diet with enough protein and fluids. This will help keep your skin healthy and able to heal quickly.
• Stay at a healthy weight, without swings of gain or loss. Weight changes can lead to increased pressure on certain body areas. They can also cause problems with support equipment that no longer fits.
• Don't smoke, and avoid tobacco smoke. Smoking dries out the skin and reduces blood supply to the skin.

What can you do to treat a pressure injury?

If a pressure injury forms, keep using the prevention steps listed above to relieve pressure and protect the skin. It's also important to keep the sore clean, covered, and slightly moist. Used together, these steps can help keep the sore from getting worse and help your skin heal.

Keep the sore clean

The pressure injury must be cleaned every time the bandage (dressing) is changed. Saline is often used for cleaning. This is a saltwater solution that you can buy at a drugstore. But there are many cleansing products for wounds. Your doctor will recommend a cleansing solution for you. In some cases, it may be okay to use tap water to clean the wound.

• Do not use cleansers made for healthy skin on an open wound.
• Avoid antiseptic solutions such as Betadine, Hibiclens, or hydrogen peroxide. These can damage new and normal tissue.
• Do not wash an open wound with water from a well. Most tap water is safe, but follow the advice of your doctor or nurse.

Keep the sore covered and slightly moist

Your doctor will recommend a bandage for the pressure injury. There are many types of bandages. Over time, your doctor may use several different kinds of bandage as the pressure injury heals.

The general idea is to keep the wound a little moist and not let it dry out between bandage changes.

• Keep the moist part of the bandage right down in the sore, placed loosely against the healing tissue.
• Cover the moist bandage with a dry bandage to help keep the sore clean and to keep the healthy skin around the pressure injury dry.

Treat pain as needed

Pain may or may not be a problem with pressure injuries. Some people who have pressure injuries do not need any pain medicine. Some need it just when the sore is being treated, and some need it on a regular schedule. If you have pain, talk to your doctor.

What other treatments may be used to treat pressure injuries?

Often a doctor will remove (debride) the dead tissue in a pressure injury. Dead tissue gives bacteria a good place to grow and can cause infection. It can also slow the growth of healthy tissue. But sometimes it is best to leave the dead tissue or scab in place and let it act as a sort of bandage. Your doctor may do this if the tissue is very stable or if the sore is not likely to heal.

Skin grafts or surgical flaps are sometimes needed. Skin grafts help new skin grow at the site of the sore if the wound extends into muscle and deeper tissues. The wound may be surgically closed to promote healing after a skin graft.

Several other treatments are sometimes used in treating pressure injuries. These are done most commonly in clinics that specialize in treating serious wounds. They include:

• Electrical stimulation. Gentle electrical current is used in and near the wound to help tiny blood vessels and new tissue to grow.
• Negative-pressure wound therapy (sometimes called "vacuum-assisted closure"). A sterile sponge or a special gauze that fights germs is placed in the sore. It's covered with a sticky bandage that does not allow any air in. The small vacuum is then turned on and kept on at all times until the next treatment. The vacuum pulls drainage from the wound and gently pulls the blood supply close to the surface of the sore. This brings nutrients to the sore and helps new tissue grow.
• Hyperbaric oxygen therapy. The person is put in a chamber where he or she breathes oxygen at high pressure. This treatment may be used to increase the oxygen level in the blood so more oxygen reaches skin and tissues. This can prevent tissue death, promote healing, and help fight infection. This treatment is not approved for treating the pressure injuries themselves. But it is approved for conditions that can occur with pressure injuries, such as bone infection (osteomyelitis) or a surgical closure of the sore that is not healing.
• Growth factor. Proteins that help new cells grow are applied to the pressure injury.
• Ultrasound. Sound waves that humans can't hear are used to create vibration and heat in the tissues. Ultrasound is being studied as a way to clean wounds and to help with healing.

Researchers continue to study these and other treatments for pressure injuries and other wounds.

How can you tell if a pressure injury is healing as it should?

As you treat a pressure injury, you will know it is healing correctly if:

• The sore is getting smaller.
• Pinkish tissue is forming along the edges of the sore, gradually moving toward the center.
• The sore bleeds a little. This means there is blood circulation in the area, which helps healing.

After a pressure injury is healed, the skin is still very fragile. It is easy for the skin to break down again, especially in the first month after the sore is healed. To decrease the risk that the pressure injury will come back, slowly return to the positions that put pressure on the area where the sore was. For example, apply pressure for no more than 15 to 30 minutes at first. Then check to see if the redness fades within 15 minutes after you take the pressure off. Talk to your doctor or nurse about a plan for returning to your normal positions and activities after a pressure injury is healed.

How can you know if a pressure injury is infected?

Open wounds, such as pressure injuries, are easy places for infections to start. Your doctor will be watching for signs of infection, and you can help watch for these signs. Tell your doctor if you notice:

• Redness or warmth in the skin around the sore, or red streaks leading away from the sore area.
• Tenderness around the sore.
• Pus in the drainage from the sore.
• A bad smell from the sore or from the bandage.
• Fever.

To treat an infection, you may use medicine, such as antibiotics, along with special care of the wound. You and the people around you will also be taught to take steps to keep germs from spreading to other parts of your body or to other people. These steps include keeping the sore covered at all times except during treatment, good hand-washing before and after caring for the pressure injury, and properly wrapping and throwing away used bandages.

How well do pressure injuries heal?

How well a pressure injury heals depends in part on its stage.

• Most stage 1 and stage 2 pressure injuries will heal within several weeks with proper treatment. Early treatment can help prevent damage and keep a sore from progressing to a more serious stage.
• Stage 3 and 4 pressure injuries are harder to treat and can take months or even years to heal. Continued care and treatment can prevent complications such as further tissue damage, infection, and pain.