dermatologic disorders
Pressure Injuries
Symptoms and Signs of Pressure Injuries
Pressure injuries at any stage may be painful or pruritic but may not be noticed by patients with blunted awareness or sensation. Several staging systems exist. The most widely used system is from the National Pressure Injury Advisory Panel (NPIAP), which classifies pressure injuries into four stages (1 to 4) according to the extent of soft-tissue damage. However, the numerical staging does not imply linear progression of pressure injuries. That is, pressure injuries do not always manifest as stage 1 and then progress to higher stages. Sometimes, the first sign is a deep, necrotic stage 3 or 4 injury. In a rapidly developing pressure injury, subcutaneous tissue can become necrotic before the epidermis erodes. Thus, a small injury may in fact represent extensive subcutaneous necrosis and damage. Similarly, the scale does not imply that healing progresses from stage 4 through stage 1. The updated NPIAP staging system also includes definitions for unstageable, deep-tissue, medical device-related, and mucosal membrane pressure injuries ( Staging definition reference ). Stage 1pressure injuries manifest as intact skin with nonblanchable erythema, usually over a bony prominence. Color changes may not be as visible in darkly pigmented skin. The lesion may also be warmer, cooler, firmer, softer, or more tender than adjacent or contralateral tissue. An actual ulcer (a defect of skin into the dermis) is not yet present. However, ulceration will occur if the course is not arrested and reversed. Stage 2pressure injuries are characterized by partial-thickness skin loss, with loss of epidermis (erosion or blister) with or without true ulceration (defect beyond the level of the epidermis); subcutaneous tissue is not exposed. The injury is shallow with a pink to red base. No necrotic tissue is present in the base. Stage 2 also includes intact or partially ruptured blisters secondary to pressure. (NOTE: Non–pressure-related causes of erosion, ulceration, or blistering, such as skin tears, tape burns, maceration, and excoriation, are excluded from stage 2.) Stage 3pressure injuries manifest as full-thickness skin loss with damage to subcutaneous tissue extending down to (but not including) the underlying fascia. The ulcers are crater-like without underlying muscle or bone exposure. Stage 4pressure injuries manifest as full-thickness skin loss with extensive destruction, tissue necrosis, and damage to the underlying muscle, tendon, bone, or other exposed supporting structures. When estimating the depth of pressure injuries for purposes of staging, it is important to take into account the anatomical location, especially in the case of stage 3 injuries. For example, the bridge of the nose, ear, occiput, and malleolus have minimal subcutaneous tissue and, consequently, pressure injuries in those locations are very shallow. However, they are still graded as stage 3 because they are as significant as deeper stage 3 injuries over locations with significant subcutaneous tissue (eg, the sacral region). Unstageablepressure injuries are characterized by full-thickness skin and tissue loss in which the extent of tissue damage cannot be determined because it is obscured by debris, slough, or eschar. If the slough or eschar is removed, a stage 3 or stage 4 pressure injury is revealed. However, stable, nonfluctuant lesions with dry eschar should never be debrided for the sake of staging. Deep-tissue pressure injuryis characterized by intact or nonintact skin with a localized area of damage to underlying tissue due to pressure and/or shearing forces. Findings include persistent, nonblanchable, purple to maroon discoloration of intact skin, and blood-filled vesicles or bullae. The area may feel firmer, boggier, warmer, or cooler compared with surrounding tissue. In this context, the termdeep-tissue pressure injuryshould not be used to describe underlying vascular, traumatic, neuropathic, or dermatologic conditions. results from the use of devices designed and applied for therapeutic purposes (eg, casts, splints). Prolonged use of poorly placed, ill-fitted medical devices can cause pressure injury to skin or mucosal membranes. Injury typically conforms to the pattern or shape of the device. The injury should be staged using the staging system. Medical device–related pressure injury has been extended to include injury caused by personal protective equipment (PPE), including face masks, continuous positive airway pressure (CPAP) masks, oxygen tubing, and other devices that are used to prevent or manage respiratory conditions such as Chronic Obstructive Pulmonary Disease (COPD) or Mucosal membrane pressure injuryappears on mucous membranes where medical devices have been in use (eg, misfitting dentures, endotracheal tubes). Because of the anatomy of the tissue, these injuries cannot be staged. This photo of a stage 1 pressure injury shows nonblanchable redness but no break in the skin. Photo from Gordian Medical, Inc. dba American Medical Technologies; used with permission. This patient has a stage 2 pressure injury on the upper right buttock (arrow). There is loss of epidermis and an erythematous base. Subcutaneous tissue is not exposed. Note surrounding areas of stage 1 pressure injury (for an example, see arrowhead) with nonblanching erythema over intact epidermis. BOILERSHOT PHOTO/SCIENCE PHOTO LIBRARY This photo of a stage 3 pressure injury shows full thickness skin loss but no exposure of muscle or bone. Roberto A. Penne-Casanova/SCIENCE PHOTO LIBRARY This photo of a stage 3 pressure injury shows subcutaneous tissue but no muscle or bone. DR BARRY SLAVEN/SCIENCE PHOTO LIBRARY This photo of a stage 4 pressure injury shows visible deep structures, such as tendon and joint. Photo from Gordian Medical, Inc. dba American Medical Technologies; used with permission. Suspect deeper tissue damage than is clinically evident in patients who have pressure injury. 1.Editors of Nursing2017: Pressure ulcers get new terminology and staging definitions.Nursing47(3):68–69, 2017. doi: 10.1097/01.NURSE.0000512498.50808.2b 