Pressure Injury Prevention and Patient Safety

Pressure injury prevention is crucial for patient safety, and nearly all pressure injuries can be prevented.

The consequences of pressure injuries are severe, as they:

• Cause patient suffering

• Prolong hospital stays

• Increase the risk of infections and, in the worst cases, lead to death

Pressure injuries also impose a significant financial burden on the healthcare system. Healthcare professionals should prioritize pressure injury prevention and actively work to ensure that patients under their care do not develop them.

The Skin and Its Integrity

The skin consists of three layers:

Between the skin and underlying soft tissues lies the fascia, a connective tissue membrane.

The epidermis is primarily composed of keratinocytes, which are continuously produced in the deepest layer and gradually move to the surface, where they eventually shed. The epidermis undergoes complete renewal approximately every 15 days.

Various factors influence skin integrity and its protective function.

Causes of Pressure Injuries

A pressure injury is damage to the skin and/or underlying tissue caused by prolonged pressure or a combination of pressure and shear forces. Pressure injuries typically develop over bony prominences but can also result from pressure from medical devices or equipment. These injuries may present as open wounds but can also exist beneath intact skin.

• Pressure: The force exerted by body weight or external pressure from medical devices, assistive equipment, or other objects. When gravity pulls the body toward a surface (e.g., a bed or chair), the skeleton presses against the skin, muscles, and other soft tissues trapped between it and the surface. This also occurs when external objects exert pressure on the skin (See Figure 2).

• Shear: A force that amplifies the effects of pressure by stretching and distorting tissues. Shear occurs when the skin remains in place while the underlying structures move, such as when a patient slides down in bed or a chair. In these cases, the skin stays in contact with the surface while the deeper tissues shift.

These forces—pressure and shear—can lead to cell damage, waste accumulation, inflammation, swelling, blood flow disruption, and tissue necrosis. The severity of the injury depends on the intensity and duration of the pressure. The exact time required for a pressure injury to develop varies depending on the patient’s condition and the surface they are resting on.

Most pressure injuries can be prevented, though in terminally ill patients, their development may be unavoidable.

Risk Factors for Pressure Injuries

There are multiple risk factors for pressure injuries, with impaired mobility being the most significant. Patients who struggle to move in bed or a chair are at increased risk of sustained pressure that can lead to tissue damage. Causes of mobility impairment include:

• Paralysis

• Reduced consciousness

• Frailty

• Severe illness

• Cognitive impairment

Reduced sensory perception also increases the risk of pressure injuries, as patients may not feel discomfort caused by pressure and shear forces and, therefore, do not reposition themselves to relieve the strain. Causes of sensory impairment include, spinal cord injuries, nerve damage, sedative medications and vascular diseases.

Other risk factors for pressure injuries include:

• Advanced age

• Excessive skin moisture or dry skin

• Malnutrition

• Fractures and Contractures

• Pain

• Acute illness

• History of previous wounds

The more risk factors a patient has, and the more severe they are, the higher the likelihood of developing a pressure injury.

Risk Assessment

International clinical guidelines recommend standardized risk assessments at the beginning of treatment to identify patients at risk of developing pressure injuries.

Following the assessment, an individualized prevention plan should be established for at-risk patients.

At Landspítali risk assessments are performed upon admission, then weekly, or sooner if the patient’s condition changes. The Braden Scale is used to assess risk levels. More information on pressure injury risk assessment can be found in the hospital’s quality document LSH-518.

For more information, you can watch this educational video on pressure injury prevention (in Icelandic).