ANSWER

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 ageing 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.
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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 and 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 damaging 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 impair blood supply and damage 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, it can cause incontinence-associated dermatitis (IAD), a type of irritant contact dermatitis caused by prolonged exposure of the skin to urine, faeces [3], or other fluids such as wound exudate and sweat. Pressure, friction, shear, and moisture (Fig. 7.1) are extrinsic factors that healthcare workers must modify to prevent skin damage.

Fig. 7.1 The primary causes of pressure injuries

Patients are vulnerable to tissue injury due to a complex interplay between various 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, resulting in decreased blood, oxygen, and nutrition supply to the tissues. Such conditions include pulmonary disease, cardiovascular disease, and diabetes. Mobility-impairing health conditions, such as osteoarthritis and neurological conditions, increase the risk of pressure injury because they limit the patient’s ability to move, mobilize, and change their position in bed or chair.

7.2.2 Pressure Injuries Classification
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 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 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-blanch-able erythema of intact skin. Each subsequent pressure injury category indicates additional tissue damage and is much more difficult to reverse than non-blanch-able erythema.

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

Skin is intact, but there is a localized area of non-blanch-able erythema. This may appear differently in people with dark skin. Visual changes may be preceded by Blanche erythema or changes in sensation, temperature, or firmness. Purple or maroon discolouration does not qualify as a colour change; these could indicate serious 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. An adverse microclimate, shear in the skin over the pelvis, and shear in the heel frequently cause these injuries. Moisture-associated skin damage (M.A.S.D.), such as incontinence-associated dermatitis (IAD), intertriginous dermatitis (I.T.D.), 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-three pressure injury.

Full-thickness skin loss with visible adipose (fat) in the ulcer, granulation tissue, and epibole (rolled wound edges). It is possible to see slough and eschar. Tissue damage depth varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunnelling are possibilities. No exposed fascia, muscle, tendon, ligament, cartilage, or bone exists. 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 eschar. Epibole (rolled edges), undermining, and tunnelling is 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 worldwide, and the advice below is based on them. Local experts responsible 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.

7.2.3.1. 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 the following:

Full skin assessment as soon as possible (but no later than 8 hours) after admission and at least daily after that, 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 include 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, discoloured, 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 discoloured skin over bony prominences indicates possible tissue damage and should be addressed immediately 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 injuries, 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; 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 pressure injuries [7] and that subsequent preventive interventions are the most important actions to be taken.

Evidence-Based Preventive Interventions (7.2.3.2)
Pressure injury prevention should be a top priority for the entire clinical team, but the nursing team typically leads it. Pressure injuries are important indicators of nursing care quality, and the occurrence of an avoidable injury is a breach of patient safety. Patient-centred assessment and interventions for the prevention and treatment of pressure injuries are required. Despite extensive research into the causes and most effective prevention methods and a wealth of evidence-based guidance, pressure injuries remain a significant problem for hospitalized patients [8]. The local, national, and global incidence of hospital-acquired pressure injuries is difficult to quantify, but they frequently account for most 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 U.K. 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 with older, dry skin and those with 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 moisturizers or emollients regularly while avoiding the use of creams and lotions. Avoid placing the patient on erythematous (red) areas 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 the 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 can 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 remobilization 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 regularly, especially if they are unable to do so themselves or have limited mobility. Good manual handling practice is essential to avoid friction and shear, and heels should be lifted free of the bed surface using pillows. The individual patient’s skin tolerance should determine the frequency of repositioning to pressure (e.g., the development of areas of blanching hyperaemia) as well as their general condition and comfort. Using the 30-degree tilt options and profiling bed functions, pressure should be relieved or redistributed, and repositioning onto bony prominences should be avoided. Once patients can sit in a chair, repositioning should be done regularly by encouraging them to stand, mobilize, and return to lying positions based on frequent skin reassessment.
Incontinence: Urine and faeces incontinence exposes the skin to excessive moisture, which can damage dermal and epidermal cells. Chemical substances in urine, faeces, sweat, and exudate are toxic to skin cells and can cause incontinence-associated dermatitis [3]. Individual continence management plans for patients with Incontinence should include immediate skin cleansing following Incontinence and using barrier creams to protect the skin. Barrier creams transferred from the skin to the pad can affect the absorbency of continence products such as pads.
Nutritional assessment and screening should be performed to identify malnourished patients or at risk of malnourishment. It is critical to ensure that the skin receives an adequate supply of nutrients, particularly protein, energy, water, and vitamins. Anyone suffering from or at risk of malnutrition requires an individualized nutrition plan (see Chap. 9 for further information).
Navigate to: 7.3. Wound Management
Because the definitive management of a 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 their hospital stay and after discharge. Due to the risk of infection, haematoma, and wound healing issues such as dehiscence, surgical wounds are a significant source of potential complications.

Surgical wounds occur under controlled conditions, and surgeons strive to ensure minimal tissue loss and good wound edge approximation during wound closure. The primary goal of wound care is for the wound to heal quickly and without complications such as infection or dehiscence (breakdown). However, many patients who have surgery after a fragility fracture are in poor general health and have multiple pre-existing health problems and medications that can interfere with healing. Deep infection after hip fracture surgery has been reported to occur between 1.5% and 7.3% of the time, depending on comorbidities [12]. Understanding the factors that can lead to poor healing and, in particular, surgical site infection, as well as the best methods to facilitate healing and prevent infection, are critical nursing activities both before and after surgery, as a well-prepared patient can make a significant difference in avoiding surgical complications and their consequences.

Wound healing is the process by which function is restored to damaged tissue after surgery. It is a dynamic, complex process influenced by the nature of the wound, pre-and post-operative management, the patient’s health status, the care environment, and the care provided. Some surgical wounds may be considered a simple interruption in the continuity of skin protection due to surgery, with rapid and predictable progress toward healing [13]. However, for the elderly patient who has undergone surgery, numerous factors increase the risk of wound healing problems such as infection, haematoma, dehiscence, sepsis, and death. To facilitate optimal wound healing, the patient’s general health and well-being must be optimized both before and after surgery, taking into account the patient’s past medical/surgical history, medications/polypharmacy, and current health history, as discussed in Chap. 4. Good Nutrition (see Chapter 8) is also critical to ensuring that wounds heal without complications, especially given the prevalence of malnutrition in elderly hospitalized patients who may have fasted for extended periods before surgery.

7.3.1. Wound Infection Prevention
Infection is a significant concern after orthopaedic surgery because 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 surgical outcomes, and delayed discharge.

Using the most recent evidence-based guidelines [14] for preventing hospital-acquired infections (HAIs) is critical to surgical site infection prevention. Such guidelines typically concentrate on the following critical interventions, which should be used for all patients following fragility fracture and surgery:

Hand hygiene must be taken seriously.
Environmental hygiene in hospitals
Specific measures for preventing surgical site infection should also be used [13], such as:

Preoperative and perioperative care must be meticulous, including skin preparation and antibiotic prophylaxis, following national and international evidence-based guidelines and medical team instructions.
Optimizing the patient’s general health and tissue perfusion through proper Nutrition and hydration
A strict aseptic technique is required when caring for wounds and removing and handling wound drains.
Taking out wound drains as soon as possible, preferably within 24 hours of surgery
Covering wounds with a suitable sterile dressing until the initial stages of wound healing are evident, and the wound surface is at least superficially sealed
removing the dressing and causing as little disruption to the wound as possible; Dressings should be removed and replaced only if there is evidence of “strike through” (blood or exudate has soaked through the dressing) or if the wound requires inspection due to pain or other symptoms of infection.
Where wound closure materials (e.g., sutures or staples) must be removed, this should be done at the appropriate time (when healing is expected) and only after a thorough examination of the wound. Wound closure materials should only be left in for as long as necessary.
Any problems with the wound should be immediately reported to the medical team; if the infection is suspected, immediate medical attention is required, and appropriate antibiotics should be prescribed.
Assess and monitor the wound in the postoperative period for signs of infection (wound breakdown (dehiscence), pain, particularly that which is increasing, redness, and wound discharge) until complete recovery; infection may appear up to 1 year after surgery in wounds involving orthopaedic implants.
Laboratory analysis of wound samples, such as swabs, can be useful in determining what organisms are colonizing the skin’s surface but is ineffective in diagnosing deep infection unless there is wound discharge. As a result, wound samples should only be taken of exudate discharge.
Go to: 7.4 Summary of Key Learning Points
A fundamental aspect of pressure injury prevention is nurses’ understanding of the pathophysiology of pressure injuries. Nurses must be able to identify risk factors for pressure injury, such as red skin, in patients who are at high risk, such as those with hip fractures. Evidence-based care should focus on skin assessment, support surfaces, keeping the patient moving by ensuring mobility and frequent changes of position, good Nutrition and hydration, and effectively managing skin moisture, particularly in incontinence.

As ageing and comorbidities affect wound healing, effective evidence-based management of surgical wounds following fragility fracture surgery can be difficult. Wound care entails careful wound assessment, observation, and infection prevention measures, all while managing the factors that influence wound healing for individual patients.