Pressure injuries (PIs) and deconditioning are complications of bed rest, which can occur after brain injury. These complications increase morbidity and mortality and have a negative impact on functional outcome after illness or injury. PIs and deconditioning create a burden for caregivers and longer length of stays, and they increase healthcare costs. Patients with brain injury are at greater risk Keywords: pressure injuries, wound care, therapy modalities, aging from the complications of bed rest, PIs, and deconditioning. It is important to identify risks of these complications and be aware of prevention and treatment measures.
Pressure injuries
Formerly called pressure ulcers , PIs are defined by the National Pressure Ulcer Advisory Panel (NPUAP) as: “localized injury to the skin and/or underlying soft tissue over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear”.
Incidence and prevalence
In the United States, prevalence ranges between 3% and 69% with an incidence of 23.5% in acute healthcare settings and slightly higher numbers in nursing homes.
Physiology and stages of healing
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Anatomy of normal skin:
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Epidermis
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Dermis
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Subcutaneous tissue
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Function of normal skin:
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Protect from trauma, dehydration, microorganisms
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Excretion of waste (perspiration)
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Sensory perception
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Vitamin D production
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Thermoregulation (vasoconstriction and dilation of blood vessels in dermis)
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Four phases of wound healing ( Fig. 30.1 ):
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Phase 1: Hemostasis: prevent further blood loss
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Immediate
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Activation of coagulation cascade and creation of blood clot
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Phase 2: Inflammation: contain injurious process
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Early
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Late
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Phase 3: Proliferation
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Granulation, angiogenesis, and reepithelialization
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Extracellular matrix remodeling
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Collagen deposition: reaches maximum 21 days after the wound is created
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Phase 4: Tissue remodeling
• Fig. 30.1
Phases of normal wound healing.
(From Ho CH, Bogie, K. In Frontera W, DeLisa J, eds. Physical Medicine and Rehabilitation: Principles and Practice . 5th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams; Wilkins Health, 2013:1394.)
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Sites
PIs are more common at bony prominences and sites of pressure or shear.
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Most frequently injured sites
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Ischium (28%)
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Sacrum (17%–27 %)
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Trochanter (12%%–19%)
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Heel (9%%–18%)
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Higher risk associated with different positions ( Fig. 30.2 )
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Supine: occiput, scapula, sacrum, ischium
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Side lying: lateral malleolus, trochanter, elbow, temporal head
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Wheelchair sitting: scapula, sacrum, ischium, heel
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Prone: forehead, elbow, knee, toes
• Fig. 30.2
Pressure injury sites based on position.
(From Ho CH, Bogie, K. In Frontera W, DeLisa J, eds. Physical Medicine and Rehabilitation: Principles and Practice. 5th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams; Wilkins Health, 2013:1395.)
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Risk factors
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Extrinsic: external to the patient’s body ( Table 30.1 )
TABLE 30.1
Extrinsic and Intrinsic Risk Factors of Pressure Injuries
Adapted from Ho CH, Bogie, K. In Frontera W, DeLisa J, eds. Physical Medicine and Rehabilitation: Principles and Practice . 5th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams; Wilkins Health, 2013:1395.
Intrinsic Risk Factors
Extrinsic Risk Factors
Muscle atrophy
Applied pressure
Impaired nutritional status
Surface shear
Anemia
Friction
Impaired vascular status
Local microenvironment
Impaired mobility
Psychosocial/lifestyle
Impaired sensation
Incontinence
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Intrinsic: within the patient’s body
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Populations with:
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Increased age
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Reduced mobility
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Complex medical conditions
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Cognitive impairments
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Motor and sensory impairment (e.g., spinal cord and brain injury)
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Assessment
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PI risk assessment scales
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Braden scale: most widely used and validated ( Fig. 30.3 )
• Fig. 30.3
Braden Scale.
(From Bergstrom N, Braden J, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Decubitus. 1988:1[2];18-19.)
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Has six subscales that quantify sensation, skin moisture, activity, mobility, shear force, and nutritional status
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A score of 12 and under indicates high risk for PI
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Norton Scale Fig. 30.4 .
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Five subscales quantify physical and mental condition, activity, mobility, incontinence
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Total score from 5 to 20; lower score indicates higher risk; score of 14 or less indicates at risk status
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Greater than 18: low risk
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Between 18 and 14: medium risk
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Between 14 and 10: high risk
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Less than 10: very high risk
• Fig. 30.4
Norton Risk Assessment Scale.
[Adapted from Norton D, McLaren R, Exton-Smith AN. An Investigation of Geriatric Nursing Problems in Hospital. Edinburgh, Scotland: Churchill Livingstone; 1962 (reissue 1975)]
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Waterlow Scale ( Fig. 30.5 )
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10 risk categories for assessment: build (body mass index [BMI]), continence, skin type, mobility, sex, age, appetite and special risks of malnutrition, neurological deficit, major surgery/trauma, medication
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Scores:
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10–14: at risk
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15–10: high risk
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20+: very high risk
• Fig. 30.5
Waterlow Scale.
(From Waterlow J. Pressure sores: a risk assessment card. Nursing Times. 81[48]:1985;49-55.)
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Staging of PIs
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Six-stage system proposed by NPUAP ( Table 30.2 )
TABLE 30.2
Staging Skin Injuries
Adapted from National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Emily Haesler, ed. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline . Osborne Park, Western Australia: Cambridge Media; 2014:44-45.
Stage 1
Nonblanchable erythema of intact skin
Stage 2
Partial-thickness skin loss with exposed dermis
Stage 3
Pressure injury: full-thickness skin loss
Stage 4
Full-thickness skin and tissue loss
Unstageable
Obscured (e.g., slough, eschar) full-thickness skin and tissue loss; depth unknown
Suspected deep tissue injury
Nonblanchable discoloration, depth unknown
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Note: Stages do not reverse (e.g., a stage IV PI does not become a stage II but rather a healing stage IV).
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Treatment
NPUAP guidelines
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Step 1: Correct risk factors
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Replace nutritional deficits, especially protein and micronutrient intake.
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Compensate for impaired mobility.
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Close monitoring of specific pressure-bearing areas
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Position change every 2 hours and orthosis or pillows to relieve pressure from heels
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Pressure reliefs every 15 minutes when sitting
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Step 2: Wound care ( Fig. 30.6 )
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Correct moisture balance
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Excessively moist wounds—cause maceration
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Excessively dry wounds—prevent granulation and reepithelization
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Debride necrotic tissue (slough and eschar) with sharps, wet-to-dry, and chemical dressings.
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Cleanse wound to facilitate removal of necrotic material, exudates, and metabolic wastes.
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Protect wound from further exposure and trauma with dressings
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