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Pressure Injury: Prevention

Pressure Injury: Prevention

Wound management and pressure injury prevention (also known as pressure ulcers) are critical aspects of patient care following a fragility fracture, particularly a hip fracture and associated surgery. Skin injury and wound healing problems are exacerbated by aging skin and multiple comorbidities. The purpose of this chapter is to give the reader an overview of evidence-based approaches to pressure injury prevention and wound management following hip fracture surgery.

Please see: 7.1. Learning Outcomes

The nurse will be able to: at the end of the chapter and after further study:
Explain the pathophysiology and causes of pressure injuries.
Recognize the risk factors for pressure injury in patients who have had a hip fracture.
Patients at risk of pressure injury should be given evidence-based care.
Discuss the factors that both hinder and promote wound healing.
Patients with surgical wounds following fragility fracture surgery should receive evidence-based care.
Please see: 7.2. Pressure Injuries
Pressure injuries are serious violations of patient safety, but they are still relatively common after fragility fractures, particularly femoral and hip fractures. The term “pressure injury” will be used because it is thought to be more accurate than “pressure ulcer” or “pressure sore” because some presentations do not involve open ulcers. Pressure injuries cause patients short- and long-term pain and distress, and are frequently viewed as indicators of poor care quality, leading to litigation. Despite the availability of evidence-based guidelines, it has been demonstrated that nurses’ knowledge of pressure injury prevention is variable [1]. This is a significant factor in the development of pressure injuries in patients during hospital and care facility admissions, as well as in the home care setting. A critical component of the service improvement process for reducing pressure injury incidence is ensuring that practitioners are well educated and have the skills and knowledge of evidence-based practice in pressure injury prevention.

Pathophysiology and Causes of Pressure Injuries 7.2.1
Pressure injuries are localized areas of soft tissue damage that typically occur in people who are elderly, have limited mobility, or are confined to a bed or chair due to an acute or chronic health problem, injury, or surgery, and who have impaired nutrition, as is frequently the case in frail patients with fragility fractures. Because of these factors, the individual’s skin and underlying tissues have a lower tolerance to forces that damage the skin and circulation. Tissue damage occurs most frequently when the skin and underlying tissues are subjected to pressure, friction, shear, or a combination of all three. Prolonged pressure, friction, or shear can result in impaired blood supply and damage to the skin and underlying tissues [2]. Moisture, usually from urinary incontinence, is another factor in skin injury; if urine comes into contact with the skin for an extended period of time, it can cause incontinence-associated dermatitis (IAD), a type of irritant contact dermatitis caused by prolonged exposure of the skin to urine, feces [3], or other fluids such as wound exudate and sweat. Pressure, friction, shear, and moisture (Fig. 7.1) are a group of extrinsic factors that healthcare workers must modify in order to prevent skin damage.
Pressure Injury: Prevention
Fig. 7.1 The primary causes of pressure injuries

Patients are vulnerable to tissue injury due to a complex interplay between a variety of intrinsic factors that affect the skin’s innate ability to resist external forces—tissue tolerance (Fig. 7.1) [2], in addition to the extrinsic factors discussed above. Coexisting medical conditions, such as those affecting the respiratory and circulatory systems, result in decreased blood, oxygen, and nutrition supply to the tissues. Such conditions include pulmonary disease, cardiovascular disease, and diabetes. Health conditions that affect mobility such as osteoarthritis and neurological conditions also increase the risk of pressure injury because they restrict the patient’s ability to move themselves, mobilise and change their own position in bed or chair.

7.2.2. Classification of Pressure Injuries
Pressure injuries are classified using the NPUAP/EPUAP/PPIA guidelines, which were updated in 2014 [4]. Understanding each classification is critical in assisting nurses and other staff in recognizing the early development of pressure injuries and preventing deterioration. The first sign of pressure injury is usually skin redness, or erythema, especially over bony prominences. In the first instance, this redness indicates a skin area that has been subjected to pressure and other forces, resulting in an inflammatory reaction that causes local blood vessel dilation. If all redness disappears when light finger pressure is applied, this is referred to as “blanching” erythema, indicating that the local capillaries are unharmed. Even before erythema appears, the patient may complain of localized pain over a bony prominence [5]. Blanching erythema indicates that the patient’s position should be changed because there is a risk of capillary damage if pressure is not relieved. Blanchable erythema is not a pressure injury, but it is an important indicator that preventive measures are required. If the forces are not removed, blanching erythema can quickly progress to pressure injury, as defined by category 1 in Box 7.1, non-blanchable erythema of intact skin. Each of the subsequent pressure injury categories indicates additional tissue damage and is much more difficult to reverse than non-blanchable erythema.

NPUAP/EPUAP/PPIA Pressure Injury Classifications [4]
Pressure Injury Category 1: Non-blanchable erythema of intact skin

Skin is intact, but there is a localized area of non-blanchable erythema. This may appear differently in people with dark skin. Visual changes may be preceded by the presence of blanchable erythema or changes in sensation, temperature, or firmness. Purple or maroon discoloration does not qualify as a color change; these could indicate deep tissue injury.

Pressure Injury Category 2: Partial-thickness skin loss with exposed dermis

The wound bed is alive, pink or red, and moist, and it may appear as an intact or ruptured serum-filled blister. Adipose (fat) tissue is not visible, nor are deeper tissues. There is no granulation tissue, slough, or eschar. These injuries are frequently caused by an adverse microclimate, shear in the skin over the pelvis, and shear in the heel. Moisture-associated skin damage (MASD), such as incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARS), or traumatic wounds, should not be described at this stage (skin tears, burns, abrasions).

Full-thickness skin loss is a category 3 pressure injury.

Full-thickness skin loss with visible adipose (fat) in the ulcer and granulation tissue and epibole (rolled wound edges). It is possible to see slough and/or eschar. Tissue damage depth varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling are possibilities. There is no exposed fascia, muscle, tendon, ligament, cartilage, or bone. This is an unstageable pressure injury if slough or eschar obscures the extent of tissue loss.

Full-thickness skin and tissue loss in Category 4 Pressure Injury

Full-thickness skin and tissue loss in the ulcer, with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. It is possible to see slough and/or eschar. Epibole (rolled edges), undermining, and/or tunneling are all common occurrences. Depth varies depending on anatomical location. This is an unstageable pressure injury if slough or eschar obscures the extent of tissue loss.

7.2.3. Preventing Pressure Injuries
Pressure injury interventions must be guided by the most recent evidence-based guidelines and coordinated by a multidisciplinary team. The NPUAP/EPUAP/PPPIA guidelines [4] provide direction for practice around the world, and the advice below is based on them. Local experts with responsibility for service improvement should lead the implementation of guidance, practice evaluation, and regular audit and monitoring of pressure injury prevalence or incidence [6]. This should include the reporting, investigation, and analysis of pressure injuries sustained in hospitals and care facilities. Patient Evaluation
The patient assessment is essential for planning effective preventive care because it provides an understanding of the risk factors that can be mitigated by effective evidence-based care. The patient’s ongoing evaluation should include:

Full skin assessment as soon as possible (but no later than 8 hours) after admission, and at least daily thereafter, or more frequently if the patient’s health deteriorates or if healthcare interventions such as procedures or surgery increase the risk of pressure injury.
Common pressure points over bony prominences such as the sacrum, buttocks, heels, back of the head, elbows, shoulders, hips (over the greater trochanter), ischial tuberosities, sides of knees, and ankles/malleoli should be examined.
Any medical and other devices (e.g., casts, urinary catheters, intravenous lines, oxygen masks, straps and ties) that can cause additional pressure points should also be noted during the assessment.
Any broken, discolored, dry/flaking, papery (thin/fragile), clammy, oedematous (puffy), or mottled skin should be noted, as these conditions increase the risk of, or indicate the presence of, tissue injury. Any red or discolored skin over bony prominences indicates possible tissue damage and should be addressed right away to prevent further deterioration.
A structured risk assessment should be performed as soon as possible (but no later than 8 hours) after admission to identify any risk of pressure injury development and individual factors that necessitate intervention. Patient characteristics that indicate a potential risk of pressure injury, such as patient age, medical conditions affecting tissue health, and drug or other therapy affecting tissue health, should be documented in the risk assessment. However, risk assessment is not an end in itself; it must be followed by active intervention to modify the risk factors.
Any existing or new pressure injuries should be documented and classified in Box 7.1 using the NPUAP/EPUAP/PPPIA classification system [4].
It must be emphasized that assessment alone is insufficient to reduce the occurrence of pressure injuries [7], and that the subsequent preventive interventions are the most important actions to be taken.

Evidence-Based Preventive Interventions (
Pressure injury prevention should be a top priority for the entire clinical team, but it is typically led by the nursing team. Pressure injuries are important indicators of nursing care quality, and the occurrence of an avoidable injury is a breach in patient safety. Patient-centered assessment and interventions for the prevention and treatment of pressure injuries are required. Despite extensive research into the causes and most effective methods of prevention, and a wealth of evidence-based guidance, pressure injuries remain a significant problem for hospitalized patients [8]. The local, national, and international incidence of hospital-acquired pressure injuries is difficult to quantify, but they frequently account for the majority of patient safety incidents. Failures in prevention that result in hospital-acquired pressure injuries can be viewed as healthcare-associated complications and are sometimes considered an indicator of nursing quality. According to the findings of a European prevalence study published in 2002, as few as 10% of patients at risk of pressure injuries were receiving adequate preventive care [9].

The UK National Health Service [10] has developed an approach to pressure injury prevention known as S.S.K.I.N. (Skin, Surface, Keep moving, Incontinence, and Nutrition), which provides a useful approach to identifying evidence-based interventions for pressure injury prevention as follows:

Skin: Keeping the skin clean and dry with unscented skin cleansers that do not irritate the skin is essential for maintaining the skin’s protective function. This is especially important for patients who have older, dry skin, as well as those who have skin allergies or other skin conditions. It is also beneficial to protect the skin’s moisture barrier by applying a light layer of simple, unscented moisturisers or emollients on a regular basis, while avoiding the use of creams and lotions. Avoid placing the patient on areas of erythematous (red) skin and massaging the skin. Massage causes friction and shear, which can harm the delicate microcirculation, resulting in inflammation and tissue damage.
Surface: Both bed and chair support surfaces should meet the needs of individual patients as well as operating tables during surgery. The choice of support surface is determined by the patient’s level of mobility; those who are primarily bedbound (e.g., while awaiting surgery or immediately following) may benefit from the use of an alternating pressure mattress, but this should never replace the need for repositioning (see keep moving below). The relative benefits of these higher-spec support surfaces in preventing pressure injuries are unknown [11]. Once the patient is able to sit up in bed, the risk of pressure injuries must be recognized and a pressure redistributing cushion must be used until the patient is fully mobile.
Keep moving: The goal of care should be to encourage remobilisation as soon as possible while also acknowledging the effects of reduced mobility during the rehabilitation phase (Chap. 6). Prolonged pressure to bony prominences and other vulnerable areas, as well as friction and shear, must be avoided by repositioning the patient on a regular basis, especially if they are unable to do so themselves or have limited mobility. To avoid friction and shear, good manual handling practice is essential, and heels should be lifted free of the bed surface using pillows. The frequency of repositioning should be determined by the individual patient’s skin tolerance to pressure (e.g., the development of areas of blanching hyperaemia) as well as their general condition and comfort. Pressure should be relieved or redistributed, and repositioning onto bony prominences should be avoided by using the 30-degree tilt options and profiling bed functions. Once patients can sit in a chair, repositioning should be carried out regularly by encouraging patients to stand, mobilise and return to lying positions depending on frequent skin reassessment.
Incontinence: Incontinence of urine and/or faeces exposes the skin to excessive moisture which can damage the dermal and epidermal cells. Urine, faeces, sweat and exudate contain chemical substances which are toxic to skin cells and can lead to incontinence-associated dermatitis [3]. Patients with incontinence should have an individual continence management plan that includes immediate cleansing of the skin following incontinence and the light use of barrier creams to protect the skin. The absorbency of continence products such as pads can be affected by barrier creams transferred from the skin to the pad.
Nutrition: Nutritional assessment and screening should be conducted to identify patients who are malnourished or at risk of malnourishment. It is essential to ensure that there is an adequate supply of nutrients—particularly protein, energy, water and vitamins—to the skin. An individualised nutrition plan is needed for anyone with or at risk of malnutrition (see Chap. 9 for further information) (see Chap. 9 for further information).
Go to: \s7.3. Wound Management
Because the definitive management of hip fracture, and some other fragility fractures that require surgical fixation, almost always involves surgery (see Chap. 5), most patients require acute wound care during the hospital stay and following discharge. Surgical wounds are an important source of potential complications due to risk of infection, haematoma and wound healing problems such as dehiscence.

Surgical wounds occur under controlled circumstances and surgeons endeavour to ensure minimal tissue loss and good approximation of the wound edges during wound closure. The main aim of care of the wound is that it should heal rapidly without complications such as infection or dehiscence (breakdown) (breakdown). However, for many patients who have surgery following fragility fracture, their general health is poor and they have multiple pre-existing health problems and medications which can significantly affect healing. It has been reported that occurrence of deep infection following surgery for hip fracture is between 1.5% and 7.3% depending on comorbidities [12]. Understanding the factors that can lead to poor healing and, particularly, surgical site infection as well as the best methods to facilitate healing and prevent infection are important nursing activities both in the pre- and post-operative period as, even preoperatively, a well-prepared patient can make a significant difference to avoiding surgical complications and their consequences.

Wound healing is the process by which function to damaged tissue is restored following surgery. It is a dynamic, complex process that is significantly affected by the nature of the wound, pre- and post-operative management, the patient’s health status, the care environment and the care given. Some surgical wounds may be considered a straightforward interruption in the continuity of the protection by the skin resulting from surgery that can be expected to make rapid and predictable progress towards healing [13]. For the older person who has undergone surgery, however, there are numerous factors which place the wound at greater risk of wound healing problems such as infection, haematoma and dehiscence as well as sepsis and death. To facilitate optimal wound healing, the general health and well-being of the patient must be optimised both pre- and post-operatively while considering the patient’s past medical/surgical history, medications/polypharmacy and current health history as discussed in Chap. 4. Good nutrition (see Chap. 8) is also central to ensuring wound healing without complications especially given the prevalence of malnutrition in elderly hospitalised patients who may have undergone lengthy periods of fasting preoperatively.

7.3.1. Preventing Wound Infection
Orthopaedic surgery results in a wound that penetrates through all layers of soft tissue to bones and joints making infection a significant worry as deep surgical site infection can lead to implant site infection (where there has been a need for surgical fracture fixation or hemi- or total arthroplasty), osteomyelitis and wound dehiscence, resulting in pain and discomfort, poor outcomes from surgery and delayed discharge.

The use of the most recent evidence-based guidelines [14] for preventing hospital-acquired infections (HAIs) is central to the prevention of surgical site infection. Such guidelines tend to focus on the following important interventions which should be employed for all patients following fragility fracture and surgery:

Careful attention to hand hygiene
Hospital environmental hygiene
Specific measures for the prevention of surgical site infection should also be employed [13] including:

Careful preoperative preparation and perioperative care including skin preparation and antibiotic prophylaxis according to national and international evidence-based guidance and medical team instructions
Ensuring the patient’s general health status and tissue perfusion is optimised through good nutrition and hydration
Stringent aseptic technique when caring for wounds and removing and handling wound drains
Removing wound drains as soon as possible, if possible within 24 h of surgery
Covering wounds with an appropriate sterile dressing until it is evident that the initial stages of wound healing have been completed and the wound surface is, at least, superficially sealed
Removing the dressing and disturbing the wound as little as possible; dressings should only be removed and replaced if there are signs that there has been “strike through” (blood or exudate has soaked through the dressing) or the wound needs inspection because of pain and other symptoms of infection
Where wound closure materials (e.g. sutures or staples) need removal, this should be done at the appropriate time (when healing is anticipated) and only following careful inspection of the wound; wound closure materials should not be left in for longer than necessary
Any identified problems with the wound should be reported immediately to the medical team; immediate medical attention is needed if infection is suspected and appropriate antibiotics should then be prescribed
Assessment and surveillance of the wound in the post-operative period for signs of infection (wound breakdown (dehiscence) pain, particularly that which is increasing, redness and wound discharge) until recovery is complete; in wounds that involve orthopaedic implants, infection may appear any time up to 1 year after surgery
Laboratory analysis of wound samples such as swabs can be useful in providing information about what organisms may be colonising the surface of the skin but is not helpful in diagnosing deep infection unless there is wound discharge. Hence, wound samples should only be taken of discharging exudate.
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