Pressure Injury

What Is a Pressure Injury?

A pressure injury—traditionally called a pressure ulcer, bedsore, or decubitus ulcer—is localized damage to the skin and underlying tissues. These injuries typically form over bony prominences such as the tailbone (sacrum), hips, heels, ankles, and elbows. They occur when prolonged force against the skin compresses blood vessels, restricting blood flow and starving tissues of vital oxygen and nutrients. Over time, this ischemia causes the affected skin and deeper structures to deteriorate.

While often associated with prolonged bed rest or wheelchair use, pressure injuries can also arise beneath medical devices such as oxygen tubing, casts, or splints. If left unaddressed on our dedicated pressure ulcer care pathway, superficial tissue breakdown can progress into a severe, deep-tissue wound.

Signs and Clinical Stages

The National Pressure Injury Advisory Panel (NPIAP) classifies pressure injuries into distinct stages based on the depth of tissue loss:

• Stage 1 Pressure Injury: Intact skin with non-blanchable redness (erythema). The area may feel warmer, firmer, or more painful than the surrounding skin.
• Stage 2: Partial-thickness skin loss involving an open wound with a pink or red wound bed, or an intact or ruptured serum-filled blister.
• Stage 3: Full-thickness skin loss where subcutaneous fat is visible, often displaying slough, undermining, or tunneling.
• Stage 4: Full-thickness skin and tissue loss with directly exposed bone, tendon, or muscle.
• Unstageable: Full-thickness tissue damage obscured by slough or dark, leathery eschar, preventing full visualization of the wound base until removed.
• Deep Tissue Pressure Injury: Persistent, non-blanchable deep red, maroon, or purple discoloration, or blood-filled blisters over intact or non-intact skin, indicating damage deep beneath the surface.

Causes and Risk Factors

The primary driver of a pressure injury is sustained external pressure, often magnified by shear (forces pulling skin in one direction while bones slide in another) and friction. Key risk factors include:

• Immobility: Inability to shift positions independently due to spinal cord injuries, stroke, post-operative recovery, or weakness.
• Sensory Loss: Neuropathy or cognitive conditions that hinder the body's natural urge to adjust position when discomfort arises.
• Moisture and Incontinence: Prolonged exposure to perspiration, urine, or stool weakens the skin barrier.
• Nutritional Deficits: Inadequate caloric and protein intake compromises tissue integrity and delays the body’s healing cascades.
• Circulatory Issues: Peripheral vascular disorders that already limit blood circulation exacerbate tissue susceptibility to pressure damage.

Evaluation and Assessment

Accurate clinical evaluation is the first step toward effective treatment. A clinician performs a detailed wound assessment to measure the wound's dimensions, determine its stage, check for structural undermining, assess exudate, and evaluate the surrounding skin. Diagnostic imaging or laboratory workups may be recommended if deeper infection or bone involvement is suspected.

Treatment Approaches

Healing a pressure injury requires addressing both the underlying mechanical causes and the local wound environment:

• Pressure Redistribution: Eliminating pressure through routine repositioning schedules and specialized support surfaces, mattresses, or cushions (pressure redistribution) is critical.
• Wound Bed Preparation: Non-viable tissue must often be cleared through clinical interventions such as sharp debridement to foster healthy granulation.
• Advanced Dressings: Specialized hydrogels, foams, or alginates maintain optimal moisture balance and protect fragile margins.
• Advanced Therapies: Complex or slow-healing wounds may benefit from advanced modalities like cellular tissue products (graft placements) or mobile bedside wound care tailored to homebound individuals.

When to Seek Professional Care

You should seek prompt medical attention if skin over a bony prominence shows persistent discoloration, warmth, or open blistering. Contact a wound specialist immediately if you observe signs of infection, such as spreading redness, swelling, severe pain, foul-smelling drainage, or systemic symptoms like fever and chills.