Pressure Injury Prevention & Management

Definition

A pressure injury is localised damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. It occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.

NPIAPEPUAPPPPIA 2019 Guidelines

Pathophysiology

Primary Mechanical Forces

Pressure: perpendicular force compressing capillaries (normal capillary pressure ~32 mmHg) — prolonged occlusion → ischaemia
Shear: parallel forces causing blood vessels to stretch/kink — particularly dangerous at sacrum when HOB elevated
Friction: surface abrasion damaging the epidermis — dragging patient up bed
Moisture: maceration weakens skin barrier integrity — incontinence/perspiration

Pathological Cascade

Capillary occlusion → tissue ischaemia (as little as 2 hours)
Ischaemia → reperfusion injury (reactive oxygen species on pressure relief)
Cell necrosis begins in deeper muscle before skin surface damage is visible
Inflammatory mediators → oedema → further impaired perfusion
Deep Tissue Pressure Injury can appear deceptively mild on surface

Muscle tissue is more vulnerable to pressure than skin — Stage 3/4 injuries can develop from inside-out before surface changes are visible. DTPI represents this pattern.

NPIAP Classification Staging System

Stage 1 — Non-Blanchable Erythema

Intact skin with non-blanchable redness. Skin may be painful, firm, soft, warmer or cooler. Difficult to detect in darker skin tones — assess by warmth, firmness, pain.

Intact Skin

Stage 2 — Partial Thickness

Partial thickness skin loss with exposed dermis. Wound bed is pink/red, moist. May present as intact or ruptured blister. Adipose not visible. No slough/eschar.

Open Shallow / Blister

Stage 3 — Full Thickness Skin Loss

Full thickness skin loss — subcutaneous fat may be visible. Granulation tissue and rolled wound edges often present. Slough/eschar may be present. Depth varies by location.

Subcutaneous Fat Visible

Stage 4 — Full Thickness Tissue Loss

Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. Slough/eschar may be present. Undermining/tunnelling common.

Bone/Tendon/Muscle Visible

Unstageable

Full thickness skin and tissue loss — depth obscured by slough (yellow/tan/grey) or eschar (tan/brown/black) covering wound base. Cannot stage until base is visible — debridement required.

Slough/Eschar Covers Base

Deep Tissue Pressure Injury (DTPI)

Intact or non-intact skin with localised area of persistent deep red, maroon or purple discolouration, or epidermal separation revealing dark wound bed. May evolve rapidly to Stage 3/4. Often more extensive than it appears.

Rapid Deterioration Risk

Device-Related Pressure Injury (DRPI)

Results from use of a medical or other device. Injury generally conforms to the pattern/shape of the device. Should be staged using the standard NPIAP staging system.

Oxygen masks/nasal cannulae
Endotracheal tube holders/tapes
Nasogastric tubes
Urinary catheters
Cervical collars, splints, casts
Sequential compression devices

Mucosal Membrane Pressure Injury

Found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these injuries cannot be staged.

Oral mucosa — ETT/bite blocks
Nasal mucosa — NG/nasotracheal tubes
Urethral mucosa — urinary catheters

Cannot be staged using the NPIAP system.

Braden Scale — Pressure Injury Risk Assessment

The Braden Scale is the most widely validated pressure injury risk tool. It assesses 6 domains with subscores. Lower total score = higher risk.

Domain	1 — Most Impaired	2	3	4 — Least Impaired
Sensory Perception Ability to respond to pressure-related discomfort	Completely limited	Very limited	Slightly limited	No impairment
Moisture Degree skin exposed to moisture	Constantly moist	Very moist	Occasionally moist	Rarely moist
Activity Degree of physical activity	Bedfast	Chairfast	Walks occasionally	Walks frequently
Mobility Ability to change/control body position	Completely immobile	Very limited	Slightly limited	No limitations
Nutrition Usual food intake pattern	Very poor	Probably inadequate	Adequate	Excellent
Friction & Shear Scored 1–3 only	Problem	Potential problem	No apparent problem	—

Very High Risk

≤9

Hourly repositioning; highest specification mattress; intensive monitoring

High Risk

10–12

2-hourly repositioning; alternating pressure mattress; full SSKIN bundle

Moderate Risk

13–14

2–3 hourly repositioning; pressure-redistributing mattress; SSKIN bundle

Mild Risk

15–18

3–4 hourly repositioning; standard mattress + foam overlay; routine monitoring

No Risk

19–23

No specific pressure care required; preventive education only

Waterlow Score

Widely used in the UK and GCC (particularly in hospitals following NHS/JCI protocols). Unlike Braden, higher Waterlow score = higher risk.

Risk Thresholds

At Risk: 10–14
High Risk: 15–19
Very High Risk: 20+

Domains Assessed

Build/weight for height (BMI)
Skin type / visual risk areas
Sex and age
Continence
Mobility
Appetite/nutritional risk (MUST)
Special risks: tissue malnutrition / neurological deficit / surgery / medication

Assessment Frequency

On admission — within 6 hours (JCI standard)
Re-assess daily for high/very high risk patients
Re-assess every 3 days for moderate risk
Re-assess on every clinical change (surgery, deterioration, new device)
Document score and date/time in patient record

Failure to document risk assessment is a medicolegal liability. Assessment without documentation = assessment not done.

High-Risk Patient Categories

Critical Care

ICU/HDU patients on vasopressors
Mechanically ventilated (prone positioning risk)
Sedated/paralysed patients
Multiple medical devices

Neurological

Spinal cord injury
Stroke with hemiplegia
Diabetic peripheral neuropathy
Sedated/anaesthetised patients

Systemic

Malnutrition / cachexia (BMI <18.5)
Oedema (poor tissue perfusion)
Peripheral vascular disease
Diabetes mellitus

Contextual

Elderly / frail patients
Faecal and/or urinary incontinence
Post-operative patients
Prolonged theatre time (>4 hrs)

Never Events

Category 3, 4 and DTPI acquired in hospital are reportable
Mandatory DATIX/incident report
Root cause analysis required
Reportable to CQC/DHA/JCI

SSKIN Bundle Overview

The SSKIN bundle is a structured preventive framework used in NHS, JCI-accredited and GCC hospitals to standardise pressure injury prevention.

S — Surface

Appropriate pressure-redistributing mattress based on risk score

S — Skin Inspection

Regular systematic skin inspection at each repositioning

K — Keep Moving

Scheduled repositioning programme with documented chart

I — Incontinence

Structured skin care regime: barrier cream, moisture wipes, SICP

N — Nutrition

MUST screening, supplementation, adequate protein intake

SSKIN Bundle — Detailed Implementation

Surface — Pressure-Redistributing Mattress

Reactive (Static) Foam/Gel:
Mild–moderate risk (Braden 13–18). Constant low pressure. Examples: Viscofoam, Tempur. Lower cost, no power required.

Alternating Pressure (Dynamic):
High–very high risk (Braden ≤12). Electrically powered cells inflate/deflate alternately to redistribute pressure. Required for ICU, immobile patients. Examples: Nimbus, Alpha Active.

Select mattress based on Braden/Waterlow score — document rationale
Check mattress integrity (no bottoming out — hand under mattress test)
Heel off surface: foam wedges/heel float devices for all patients with Braden ≤14
Operating theatre table overlay for procedures >2 hours
Wheelchair/chair cushion for chairfast patients (gel/foam pressure-relieving)

Skin Inspection — Systematic Assessment

Full skin assessment minimum every 2 hours (at each repositioning)
Inspect all bony prominences: sacrum, coccyx, heels, malleoli, ischial tuberosities, trochanters, occiput, elbows, scapulae
Inspect all medical device contact points every shift (minimum 8-hourly)
Assess for non-blanchable erythema using blanching test (finger pressure test or glass tumbler)
In darker skin tones: assess warmth (local heat >1°C), firmness/induration (boggy or firm), and patient-reported pain/discomfort
Use body map/wound chart for documented findings with date and time
Photograph any skin changes — time-stamped clinical photography

Dark-skinned patients are at higher risk of undetected Stage 1 injuries — visual erythema assessment is insufficient. Use palpation and temperature assessment.

Keep Moving — Repositioning Programme

Frequency:

Minimum every 2 hours for all at-risk patients
Every 1 hour for very high risk (Braden ≤9) or if pressure injury present
Use repositioning chart — document position, time, skin inspection findings, nurse signature

Technique:

30-degree lateral tilt — NOT 90-degree (avoids direct pressure on greater trochanter)
Avoid placing patient directly on existing pressure injury
Avoid positioning over medical devices where possible
Use slide sheets — never drag patient across surface
Semi-recumbent: head of bed 30° maximum (to reduce shear) unless clinical contraindication

30-degree lateral tilt is evidence-based — it offloads sacrum and trochanters simultaneously. 90-degree lateral position places full body weight on greater trochanter.

Heel Protection Bundle:

Heels must be completely offloaded from bed surface — foam heel props or commercial heel float devices
Do NOT use rings/donuts — they create circular pressure
Inspect heels every 2 hours — particularly in diabetic, vascular and post-operative patients
Heel dressings (e.g. Mepilex Border Heel) for very high risk patients as prophylactic dressings

Incontinence — Moisture Management

Moisture-Associated Skin Damage (MASD) — distinct from pressure injury but co-exists and increases risk
Implement SICP — Structured Skin Integrity Care Plan
Cleanse skin after each episode of incontinence using pH-balanced skin cleanser (pH 4–5.5)
Apply barrier cream/film after each cleanse (e.g. Cavilon No-Sting Barrier Film, Sudocrem)
Avoid soap and water — alkaline pH disrupts skin's acid mantle
Identify and treat underlying cause of incontinence: UTI, constipation, drug side effects
Consider continence aids: containment products, catheterisation (if clinically appropriate)
In GCC context: hot climate increases perspiration — moisture management extends to perspiration and wound exudate

Nutrition — Nutritional Assessment & Support

MUST Screening (Malnutrition Universal Screening Tool):

Perform on admission and weekly thereafter
Score 0: Low risk — routine care
Score 1: Medium risk — observe/document 3-day dietary intake
Score 2+: High risk — refer to dietitian, initiate nutritional support

Nutritional Requirements for Wound Healing:

Protein: 1.2–1.5 g/kg/day (increased for wound healing)
Calories: 30–35 kcal/kg/day
Fluid: 30–35 mL/kg/day
Vitamin C: collagen synthesis
Zinc: cell proliferation and immune function
Arginine: specific wound healing supplements (e.g. Arginaid, Cubitan)

TIME Framework — Wound Assessment

T — Tissue Type

Black	Necrotic/eschar — devitalised tissue, requires debridement
Yellow	Slough — fibrinous material, requires debridement
Red	Granulating — healthy healing tissue, protect and maintain
Pink	Epithelialising — new skin growth at wound edges

I — Infection / Inflammation

Contamination: micro-organisms present, no host response
Colonisation: organisms present, multiplying, no host response
Critical Colonisation: delayed healing, increased exudate, wound pain — treat with antimicrobial dressing
Local Infection: cellulitis, erythema >2cm, warmth, pain, purulent exudate
Systemic Infection: fever, raised WCC, sepsis — systemic antibiotics, urgent review

M — Moisture Balance

Assess exudate level: none / low / moderate / high
Assess exudate type: serous / serosanguineous / haemosanguineous / purulent
Dry wound bed: needs moisture donation (hydrogel/hydrocolloid)
Heavily exuding: needs absorption (foam/alginate)
Macerated periwound skin: barrier film before dressing

E — Edge of Wound

Advancing edge: healing progressing — continue current treatment
Non-advancing edge: rolled/raised edges — stalled healing, consider debridement/reassessment
Undermining: tissue destruction beneath wound edge — probe with cotton-tipped applicator, document with clock positions
Sinus/tunnelling: document depth and direction

Wound Measurement & Documentation

Measurement Technique

Length × Width: greatest length (head-to-toe axis) × greatest width (side-to-side)
Depth: sterile probe to deepest point (cm)
Undermining: probe inserted along wound edges — document o'clock positions and depth
Measure at every dressing change — document on wound assessment chart
Clinical photography: time-stamped, with ruler, patient consent obtained

Wound Swab — Levine Method

Clean wound first with sterile saline — remove surface debris
Use moistened sterile swab (normal saline)
Apply 10-point Levine technique: 1 cm² area, rotating swab with sufficient pressure to express fluid from wound tissue
Targets deep wound tissue flora rather than surface contaminants
Label specimen: wound site, date, time, clinical indication
Send immediately to microbiology

Dressing Selection by Wound Type

Wound Condition	Goal	Dressing Type	Examples
Necrotic / Eschar	Autolytic debridement	Hydrocolloid / Hydrogel	DuoDERM, Intrasite Gel, Aquaform
Sloughy Yellow	Debridement + moisture balance	Hydrocolloid / Hydrofibre / NPWT	DuoDERM Extra Thin, Aquacel Extra
Infected / Critical Colonisation	Antimicrobial, biofilm disruption	Silver-containing dressings	Mepilex Ag, Aquacel Ag, Biatain Ag
Moderate exudate, granulating	Absorb exudate, protect tissue	Foam dressing	Mepilex Border, Biatain, Allevyn
Low exudate, epithelialising	Maintain moist environment	Thin film / thin hydrocolloid	Tegaderm, DuoDERM Thin, Opsite
High exudate	High absorption	Alginate / hydrofibre	Kaltostat, Aquacel, Sorbsan
Cavity / sinus	Fill dead space, absorb	Ribbon/cavity foam	Aquacel ribbon, Allevyn cavity
Prophylactic — high risk site	Prevent pressure injury	Multi-layer soft silicone foam	Mepilex Border Lite, Allevyn Life

Silver dressings should not be used long-term without reassessment — use for 2-week trial maximum then review. Silver resistance is an emerging concern.

Surgical Debridement & NPWT

Surgical Debridement Indications

Extensive necrosis — large eschar not responding to autolytic methods
Infection tracking / spreading cellulitis / sepsis source
Stage 4 pressure injury with bone/tendon involvement
Osteomyelitis (bone infection) requiring surgical clearance
Sharp/surgical debridement by trained clinician (TVN/surgeon/doctor)
Enzymatic debridement: Collagenase (Santyl) — adjunct option

NPWT — Negative Pressure Wound Therapy

Continuous or intermittent sub-atmospheric pressure (-80 to -125 mmHg)
Promotes granulation, reduces oedema, removes exudate
Indications: large cavity wounds (Stage 3/4), post-surgical wounds, dehisced wounds
Contraindications: untreated osteomyelitis, malignancy in wound, unexplored fistula, dry necrosis (eschar)
Change foam every 48–72 hours (or per manufacturer guidance)
Devices: V.A.C. (KCI), Avelle, PICO (closed incision NPWT)

Documentation Standards

Documentation is a legal record. Incomplete, inaccurate or delayed documentation constitutes a breach of professional duty.

Required Documentation Elements

Initial skin assessment on admission (date/time/nurse name)
Risk assessment score (Braden/Waterlow) with total and subscores
Body map marking of all skin findings
Wound assessment chart (TIME framework, measurements)
Time-stamped clinical photography with consent
Repositioning chart: position, time, skin check, signature
Dressing change record: wound appearance, dressing used, next change date
Nutritional screening score and actions taken
Patient/family education provided — what, when, who
Tissue viability nurse referral and outcome

Incident Reporting — DATIX / Never Events

Category 3, 4 and DTPI acquired in hospital are mandatory incident reports
Report within 24 hours of identification
Distinguish: ward-acquired vs community-acquired vs unavoidable
DATIX: detail wound location, stage, date first noted, risk factors, preventive measures in place
Category 4 and DTPI: trigger formal root cause analysis (RCA)
RCA examines: assessment adequacy, repositioning compliance, equipment use, documentation, staffing
Actions shared with ward team as learning outcome

Category 3/4 pressure injuries in NHS/JCI context are treated as Never Events if acquired in hospital and deemed avoidable.

Tissue Viability Nurse (TVN) Referral

Referral Triggers

Any Category 2 pressure injury not improving within 2 weeks
Any Category 3 or 4 pressure injury — automatic referral
Any DTPI (Deep Tissue Pressure Injury)
Unstageable wound requiring specialist debridement assessment
Complex wound: fistula, sinus, tunnelling, osteomyelitis suspected
Patient requiring NPWT initiation or review
Wound not responding to 2 weeks of standard treatment

Legal & Professional Framework

Duty of care: nurse has legal obligation to provide competent pressure injury prevention
Negligence: failure to assess, prevent, treat or document can constitute clinical negligence
NMC Code (UK) / DHA/SCFHS Standards: registered nurses responsible for maintaining competency in wound care
Hospital Trust / facility liable for systemic failures: staffing, equipment, education
Cost per pressure ulcer: £1,214–£14,108 depending on category (NHS data)

Patient & Family Education

In-Hospital Education

Explain what pressure injuries are and why patient is at risk
Demonstrate repositioning technique for self-repositioning (if able)
Teach pressure-relieving positions: 30° tilt, pillow under calves
Encourage patient/family to report new skin pain, redness, warmth
Nutritional guidance: high-protein diet, hydration importance

Discharge Planning & Community Referral

Carer training: repositioning, skin inspection, dressing technique
Prescribe appropriate pressure-relieving cushion for wheelchair/chair use
Community wound care referral: district nursing / community TVN
Provide written wound care plan with dressing type, frequency, review date
Red flags for GP/ED re-referral: wound deterioration, infection signs, fever

GCC-Specific Context

Accreditation Standards in GCC

JCI (Joint Commission International): pressure injury prevention in IPSG.6 — international patient safety goals
CBAHI (Saudi Arabia): NSCP standards include pressure injury rates as quality indicator
DHA (Dubai Health Authority): tissue viability standards aligned with NICE/NHS frameworks
DOH (Abu Dhabi): hospital quality standards include wound care competency
SCFHS (Saudi Commission for Health Specialities): pressure injury content in nursing licensing exams
Pressure injury rate reported as hospital quality indicator — lower rates linked to accreditation scores

GCC-Specific Clinical Challenges

High ICU-to-bed ratios in GCC tertiary hospitals — concentrated very high risk population
Hot climate: increased perspiration → moisture-associated skin damage (MASD) even in non-incontinent patients
Moisture management extended to sweat and wound exudate in air-conditioned and non-air-conditioned settings
Diverse patient population: different skin tones require adapted Stage 1 assessment methods
High rates of diabetes mellitus and obesity in GCC — peripheral neuropathy and vascular risk factors common
Availability of alternating pressure mattresses varies — document when unavailable and escalate

Darker Skin Tone — Assessment Adaptation

Standard blanching test and visual erythema assessment can miss Stage 1 injury in patients with darker Fitzpatrick skin types (IV–VI).

Palpate for localised warmth — may present as warmer than surrounding tissue
Palpate for firmness or bogginess (oedema vs induration)
Ask patient: localised pain, tenderness or burning sensation
Use subdued lighting at different angles to detect colour change
Compare symmetrically — assess equivalent area on opposite side
Purple/maroon hue rather than red — indicates DTPI in darker skin

MASD vs Pressure Injury — Differential

Feature	MASD	Pressure Injury
Cause	Moisture/chemical	Pressure/shear
Location	Skin folds, perineum	Bony prominences
Shape	Irregular/diffuse	Regular, defined
Depth	Superficial	Can be deep
Edges	Irregular, 'kissing' lesions	Regular/distinct

SCFHS / DHA / DOH Exam Preparation

Braden Scale — Key Exam Points

Total range: 6–23
6 domains (not 5, not 7)
Friction & Shear scored 1–3 only
Very high risk: ≤9
No risk: ≥19
Lower = higher risk

NPIAP Staging — Key Exam Points

Stage 1: intact skin, non-blanchable
Stage 2: partial thickness, blister OK
Stage 3: fat visible, NOT bone
Stage 4: bone/tendon/muscle visible
Unstageable: eschar/slough obscures — cannot be staged
DTPI: deep purple/maroon, intact OR broken skin

SSKIN — Key Exam Points

S = Surface (mattress)
S = Skin inspection
K = Keep moving (repositioning)
I = Incontinence management
N = Nutrition
2-hourly minimum repositioning
30° lateral tilt (not 90°)

Dressing Selection — Exam Points

Silver = infection/critical colonisation
Foam = moderate exudate
Hydrocolloid/hydrogel = dry/necrotic
Alginate = high exudate
Thin film = epithelialising/low exudate
NPWT = cavity/Stage 3–4

Legal — Exam Points

Cat 3/4/DTPI = mandatory incident report
Cat 4/DTPI = Root Cause Analysis
TVN referral: Cat 2 not improving / any Cat 3+
Cost: £1,214–£14,108 per ulcer
Never Event = avoidable Cat 3/4 hospital-acquired

TIME Framework — Exam Points

T = Tissue (necrotic/slough/granulating/epithelialising)
I = Infection/inflammation
M = Moisture balance
E = Edge of wound
Levine method = wound swab technique

Pressure Injury Prevention & Management Advanced Guide