What is pressure injuries?

Pressure injuries: Overview

A pressure injury on the skin is caused by constant pressure to that area. The pressure damages the skin and underlying tissues, creating an injury. This can happen when you lie in bed or sit in a wheelchair for a long time. And it can happen much more quickly when the health of your skin is affected by problems like poor nutrition or a disease that affects your blood circulation.

Pressure injuries usually occur over bony areas, such as your sit bones, hips, lower back, elbows, heels, and shoulders. They also can occur in places where the skin folds over on itself. You may have mild redness or open wounds that are harder to heal.

Good care at home can help heal pressure injuries. This includes keeping pressure off the area and following your doctor's instructions on caring for your injury. Eating a healthy diet with enough protein can also help with healing.

Pressure injuries

A pressure injury (pressure ulcer) is caused by constant pressure to an area of skin. The pressure damages the skin and underlying tissue, creating an injury.

This often occurs when a person lies in bed or sits in a wheelchair for a long time. Pressure injuries usually form over bony areas such as your sit bones, hips, lower back, elbows, and heels. To prevent pressure injuries, you need to change positions often.

Severe pressure injuries are hard to treat and slow to heal. If they don't heal, they can lead to skin, blood, or bone infections.

Pressure injuries

Early-stage and late-stage pressure injuries.

Pressure injuries develop when constant pressure on an area of skin damages the skin and underlying tissues, creating an injury. Pressure injuries can range from mild reddening of the skin (early stage) to severe tissue damage that extends through the skin and soft tissue and into the bone (late stage).

What are the symptoms of pressure injuries?

At first, the skin may appear reddened. Or the skin may look purple or dark red. In darker skin, the color may differ from that of nearby skin. The injury may be tender and warm to the touch. It may break open or form an ulcer where fat, bone, or muscle may be visible.

How are pressure injuries treated?

Treatment focuses on helping the pressure injury heal. This involves keeping pressure off the area. Injuries with unbroken skin may need to be kept clean and bandaged. For open injuries, your doctor may remove dead tissue from the wound to prevent an infection. You may need special dressings. Some people may need surgery.

Preventing pressure injuries

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 damages the skin and underlying tissues. Pressure can be relieved and spread in several ways. Often a combination of these is best.

  • Change position often.
    • In a bed, change position every 2 hours. Learn how to move yourself so that you avoid folding and twisting your skin.
    • In a wheelchair or other type of chair, shift your weight every 15 minutes.
    • Try not to slide or slump across sheets in a chair or bed. Recliner chairs are likely to allow slipping, so don't sleep in a recliner. Try to keep the head of a bed, a recliner chair, or a reclining wheelchair raised no more than 30 degrees.
  • 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.
    • If you have problems with bowel or bladder control, clean your skin right away if it gets 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.
    • If you have dry skin, use moisturizing cream or lotion to keep your skin from drying out and cracking.
    • 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.
      • 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.
  • Make healthy choices.
    • Eat healthy foods with enough protein, and get plenty of fluids. That can help damaged skin heal and help new skin grow.
    • Stay at a healthy weight. Both weight gain and weight loss can make pressure injuries more likely. Weight changes can also cause problems with support equipment that no longer fits.
    • Don't smoke. Smoking dries the skin and reduces blood supply to the skin.
  • Talk to your doctor about pressure-relieving cushions and pads.
    • Use special support surfaces. There are mattresses, bed covers, and chair cushions designed to help reduce and spread pressure.
    • Ask your doctor which cushions and pads might help you. Some products, such as doughnut-type devices, may actually cause pressure injuries or make them worse.

If you or someone you care for is not able to move much, it's important to prevent pressure injuries and to check the skin every day. If you think that a pressure injury is forming, take steps to treat it. Talk to your doctor or nurse about what more you can do.

How are pressure injuries diagnosed?

A doctor can diagnose a pressure injury by examining it. In some cases, the doctor may want to do blood tests to check for infection or to see if you're getting enough protein in your diet. The doctor may also want to do a skin and wound culture or a skin biopsy.

How can you care for yourself when you have pressure injuries?

  • Change positions often. For example, change positions about every 2 hours when lying down and every 15 to 30 minutes while sitting. Try setting a timer to remind yourself.
  • If your doctor prescribed a medicated ointment or cream, use it exactly as prescribed. Call your doctor if you think you are having a problem with your medicine.
  • Wash pressure injuries every day, or as often as your doctor recommends. Most tap water is safe, but follow the advice of your doctor or nurse. They may recommend that you use a saline solution. This is a salt and water solution that you can buy over the counter.
  • Put on bandages as your doctor or wound care specialist says.
  • Keep healthy tissue around the sore clean and dry.
  • Check your skin every day for sores (or have a caregiver do it).
  • If you know what caused the injury, find a way to remove that pressure.

Common areas where pressure injuries develop

Areas where pressure injuries commonly develop.

Pressure injuries are caused by constant pressure on the skin. They often form on skin that covers bony areas. Common sites include the back of the head and ears, the shoulders, the elbows, the lower back and buttocks, the sit bones, the hips, the inner knees, and the heels.

Pressure injuries may also form in places where the skin folds over itself. And they can occur where medical equipment puts pressure on the skin. For example, they may form where oxygen tubing presses on the ears or cheeks.

What are pressure injuries?

A pressure injury on the skin is caused by constant pressure to that area. The pressure damages the skin and underlying tissues, creating an injury. This can happen when you lie in bed or sit in a wheelchair for a long time.

Pressure injuries usually occur over bony areas, such as your sit bones, hips, lower back, elbows, heels, and shoulders. Pressure injuries can also occur in places where the skin folds over on itself, or where medical equipment presses on the skin, such as when oxygen tubes press on the ears or cheeks.

Pressure injuries can range from red areas on the surface of the skin to severe tissue damage that goes deep into muscle and bone. Severe injuries are hard to treat and slow to heal. When pressure injuries do not heal properly, problems such as bone, blood, and skin infections can develop.

What causes pressure injuries?

Pressure injuries are caused by constant pressure on the skin and tissues.

Other things that can make pressure injuries more likely include:

  • Sliding down in a bed or chair (shear force).
  • Being pulled across bed sheets or other surfaces (friction).
  • Not getting enough nutrition to keep your body working well (malnutrition).
  • Not being able to get out of bed or walk around (immobility).
  • Having a disease that affects how well blood circulates in your body, such as diabetes or peripheral arterial disease.
  • Excess moisture, such as from sweat, urine, or feces. Skin that is often wet is more likely to break down and form pressure injuries.

Stages of pressure injuries

The four stages of pressure injuries.

Pressure injuries are injuries to the skin and underlying tissue. They can range from mild reddening of the skin to severe tissue damage—and sometimes infection—that extends into muscle and bone. Pressure injuries are described in the following stages.

  • Stage 1 pressure injuries are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 injury can feel either firmer or softer than the area around it.
  • Stage 2 pressure injuries are open wounds. The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The wound expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
  • Stage 3 pressure injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone.
  • Stage 4 pressure injuries extend to muscle, tendon, or bone.
  • Unstageable pressure injuries are when the stage is not clear. In these cases, the base of the wound is covered by a layer of dead tissue that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the wound to determine the stage.
  • Deep tissue pressure injuries are when there isn't an open wound, but the tissues beneath the surface have been damaged. The area of skin may look purple or dark red, or there may be a blood-filled blister. If you or your doctor suspect a pressure injury, the area is treated as though a pressure injury has formed.

Serious complications, such as infection of the bone (osteomyelitis) or blood (sepsis), can occur if pressure injuries progress.

Pressure injuries: When to call

Call your doctor now or seek immediate medical care if:

  • You have signs of infection, such as:
    • Increased pain, swelling, warmth, or redness.
    • Red streaks leading from the sore.
    • Pus draining from the sore.
    • A fever.

Watch closely for changes in your health, and be sure to contact your doctor if:

  • Your pressure injuries are not healing.
  • You have new pressure injuries.
  • You need help changing positions in bed or in a chair.
  • Your caregiver needs help to move you.

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