Pressure Injury

Editor's Note: How can facilities lower their hospital-acquired pressure injury (HAPI) rates? In this interview, Kelly McFee, DNP, FNP-C, CWS, CWCN-AP, FACCWS, DAPWCA discusses setting up a pressure injury prevention program at her facility with a focus on multidisciplinary efforts, along with resources that helped move this initiative along.

Editor's Note: How can clinicians help support caregivers who look after family members with pressure injuries? In this interview, Kelly McFee, DNP, FNP-C, CWS, CWCN-AP, FACCWS, DAPWCA discusses how to educate caregivers on pressure injury prevention and what resources exist for caregivers for further insight.

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At-risk patient – diabetic foot ulcers: Individuals with diabetes have a higher risk of ulceration, typically on the lower extremities. Other factors contributing to the risk of ulceration include peripheral neuropathy, peripheral arterial disease, infection, and pressure.

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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.

By Karen Lou Kennedy-Evans, RN, FNP, APRN-BC, and Leslie Ritter, PhD, RN

Recently, WoundSource had the opportunity to talk with Karen Lou Kennedy-Evans, RN, FNP, APRN-BC, and Leslie Ritter, PhD, RN, via email about their presentation, “Thermographic Imaging of Terminal Skin Changes," for the NPIAP Spring 2023 Conference, which took place in San Diego, California, March 18, 2023.

In this presentation, the authors state that the appearance of the Kennedy lesion (KL) and a deep tissue pressure injury (DTPI) are often similar, and, according to the speakers, it can cause a challenge for clinicians in their ability to make a visible determination of the wound. Thermographic imaging, they claim, can be used to measure and note changes in a patient’s skin at the end of their life.

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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.

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The National Quality Forum (NQF) introduced the term never event in the early 2000s, and it refers to a preventable error that may represent fundamental issues with the quality or safety of care within a medical setting. This wording was initially selected because these events are situations that should never happen to any patient, such as surgery to the wrong leg or leaving a sponge in a patient after surgery. In recent years, the NQF has adopted the term serious reportable events (SREs), but in many instances, the term never event is still used.

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Avoidable pressure injury: The development of a new pressure injury or the worsening of an existing one that results from a failure of the facility or caregivers to adequately identify, prevent, or manage the patient using acceptable care standards.

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In chronic wound management, clinicians often see and treat both partial- and full-thickness wounds. These wounds may present as pressure injuries or other wound types, including, although not limited to burns, trauma wounds (skin tears, abrasions, lacerations), vascular wounds, diabetic wounds, and surgical wounds. It is vital to differentiate partial- versus full-thickness wounds for a multitude of reasons, such as to understand how they heal, guide treatment, and ensure clear accurate documentation, to name a few.

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By Janet Wolfson, PT, CLWT, CWS, CLT-LANA

A 55-year-old African American male was admitted to our inpatient rehabilitation facility (IRF) with a right trochanter stage 4 pressure injury, sacral stage 3, and left below the knee amputation (L BKA) with comorbid diabetes mellitus (DM) and end-stage renal disease (ESRD). A 2-person skin assessment was completed on admission by 2 RNs, one of whom had worked in a wound clinic for several years. While changing his negative pressure wound therapy device on his right hip 1 week later, I decided to check his right heel. He had evidence of callus and ashy skin, but I thought I could see an injury curved around the callus area, as seen in image 1. Upon further inspection, I discovered a stage 2 blister approximately 4x5 cm. The skin had the texture of dry, crumpling, thin cardboard. He had no sense of pain in the area. As an amputee, he did not have another heel to compare temperature, texture, or color.

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