Similar to other medical conditions such as high blood pressure or diabetes, what you don’t see can hurt you. Unfortunately, just because you can’t see symptoms or indicators, it doesn’t mean damage or harm isn’t being done.
With regards to the skin, damage to the soft tissue may not be immediately visualized. Damage done at the bony interface may not show at surface level for several hours up to 5 days later, therefore, it is important to do a thorough assessment, and get a history and physical upon patient admission.
This same phenomenon may occur with pressure injuries. According to the National Pressure Injury Advisory Panel (NPIAP), a pressure injury is “localized damage to the skin and 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. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”1
“Even when pressure and subsequent hypostasis have resulted in a tissue injury and ulcer, conditions such as diabetes, peripheral arterial disease, lymphedema, peripheral neuropathy, immobility (from any cause), connective tissue disorders, malignancies, lower extremity contracture, and other conditions may exacerbate the situation.”2
For individuals that are higher risk, NPIAP guidelines recommend tissue offloading using a device and frequent repositioning to distribute load. Clinicians should also consider a more advanced support surface that helps decrease pressure on the tissues and provides maximum immersion and envelopment over contact areas of the body (reactive therapy). An active support surface can provide offloading through the cyclical changes that occur in the cells during the inflation/deflation cycles of an alternating pressure support surface.
Identification and staging of pressure injury may vary between the assessments of a wound care nurse vs the patient care provider, a novice staff vs an experienced clinician. Is the damage really a pressure injury or is it something else? NPIAP recommends a thorough skin assessment and careful evaluation, as well as a comprehensive chronologic history of injury, identification of the reason of such injury, and effective wound care as the initial steps to the prevention and healing the pressure injuries.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: The International Guideline 2019. Emily Haesler (Ed.). EPUAP/NPIAP/PPIA:2019.
- Bell, D. Podiatry Today. “Pertinent Principles in Healing Heel Ulcers. August 26, 2019, Volume 32-Issue 7, p28-34. https://www.podiatrytoday.com/pertinent-principles-healing-heel-ulcers.