Avoidable Pressure Injury

There has been much discussion surrounding unavoidable skin breakdown; however, the exact etiology remains unknown. Experts have discussed hypoperfusion and multiorgan system failure as contributing factors. Unavoidable pressure injuries typically have clinical features that distinguish them from true pressure injuries. These features include butterfly, pear, or horseshoe-shaped discoloration (maroon, red, purple, black), which quickly develop on the sacrum, buttock, spine, and extremities in the absence of external pressure. These areas of breakdown can evolve in hours, from intact skin to a deep wound exposing muscle, bone, or tendon, and they often develop in months, weeks, days, or hours prior to death.

As the body's largest organ, skin has multiple functions, causes, and manifestations of failure at end of life. The concept of skin failure was first proposed in 1991 and continues to impact how injuries at end of life are understood. Skin failure is often discussed alongside mention of unavoidable pressure injuries, which develop despite implementation of prevention measures, best practices, and monitoring. For patients who are critically ill, these pressure injuries may be categorized as acute skin failure depending on the pathophysiological factors that led to their development.