Managing Pressure Injuries: 6 Key Considerations

Published on October 19, 2022 by Carole Jakucs, MSN, RN, PHN, CDCES

Wound care is an exciting specialty that requires continuous learning.

With various wound types and multiple wound care products and treatments available, clinicians strive to stay up to date on evidence-based practices to ensure they are providing patients with current standards of care.

Managing pressure injuries is one area of wound care that many wound care professionals encounter regularly, as they are pervasive across the healthcare continuum.

Whether you work in home health, acute care, or long-term care, you should be aware of some key concepts when managing pressure injuries, as explained by Don Wollheim, MD, FAPWCA, WCC, DWC.

Wollheim is a board-certified surgeon of the American Board of Surgery with 25 years of experience in general/vascular surgery and 16 years as a wound care specialist and educator. He is also a medical-legal consultant, college science instructor, supervising physician for a hyperbaric oxygen clinic, and clinical instructor at the Wound Care Education Institute (WCEI).

Wollheim outlined some important considerations when caring for patients with pressure injuries.

Pressure injuries are dynamic

It is important to note that what was practiced in the past may not be what is done today, according to Wollheim. Additionally, what is done today may not be deemed a best practice in the future and it is often best to consider “standard of care” a moving target, and determine the appropriate therapy for that point in time.

One example is evaluating the timing of conducting a Braden Scale wound assessment to predict skin breakdown in patients.

“For many years the practice was to conduct a Braden Scale assessment within 24 hours upon admission to a facility,” he said. “The guideline now is conducting a Braden Scale risk assessment within eight hours of admission. This illustrates the changing — moving target — of standard of care and the result of scientific findings that pointed out that 24 hours may be too late for some patients. Necrotic tissue might present much sooner — and as soon as six hours. Timely administration of the Braden Scale along with using it correctly is essential.”

Another common wound care practice in years past was utilizing wet-to-dry dressings.

Even though this is the most frequently ordered dressing, it is now seen as an outdated practice and no longer should be considered the standard of care, Wollheim said.

Changing terminology and documentation

When terminology changes, so does the required charting that accompanies the name changes — the new terms need to be used instead of the older, outdated ones, Wollheim said.

Pressure injuries used to be called decubitus or pressure ulcers.

In 2016, the National Pressure Injury Advisory Panel recommended the name change to pressure injury.

Another change has been a revision of the staging system for pressure injuries along with their numbering. Roman numerals are no longer used. Instead, Arabic numbers are standard practice.

Paying attention to the healing rate of wounds

Clinicians caring for wounds will want to monitor how quickly a wound is healing, Wollheim explained.

“We want a wound to heal as quickly and painlessly as possible,” he said. “The goal is to see a wound reduce in its area by 50% within three to four weeks of initiating treatment.” That is the cross-sectional area (in cm2) obtained by multiplying the length (in cm) by the width (in cm).

If the wound does not heal as quickly as expected, clinicians should assess if a change in treatment is necessary.

Using TCOM to predict if a wound has enough oxygen

One trend in wound care is the use of transcutaneous oximetry, also known as TCOM, Wollheim said.

“Using TCOM tells you how much oxygen is diffusing from the capillaries surrounding a wound bed,” he said. “Knowing this level is very helpful for predicting if a wound has enough available oxygen that is necessary to heal.”

To heal a wound requires more energy for the healing process than just maintaining non-wounded tissue.

The ATP molecule is the energy unit of the cell. Its production is directly related to the oxygen available to the cell. When there are low levels of oxygen available (that is, a hypoxic environment), that results in significantly less ATP production than in an oxygen-rich environment.

TCOM gives an idea of the amount of oxygen available for ATP production and thus wound healing.

There is a good chance a wound might not heal if the TCOM level is 30 mmHg or less, according to Wollheim. But if the TCOM is 40 mmHg or higher, there is a good chance the wound will have enough oxygen for healing in a timely fashion.

In the hypoxic environment, the clinician might consider revascularization or hyperbaric oxygen therapy to get more oxygen to the wound for ATP production and wound healing.

Educating colleagues about evidence-based practices

When knowledgeable clinicians encounter an order for the wrong materials or treatment, or they see a colleague practicing an outdated or unproven method, they should consider being proactive in educating their colleagues, Wollheim said.

“When differences arise, it is best to approach an ordering clinician or colleague in a non-judgmental and collaborative way,” he said. “You’ll likely get less resistance, and the other person may realize they can learn something from you.”

Try an educational, open-minded approach with the ordering clinician, and think about finding a way to have a private, one-on-one encounter. This might be less embarrassing or intimidating to the clinician and allow them to save face.

Another option to help other clinicians learn about appropriate wound care is to schedule webinars or educational lectures.

“The timing of this educational event is quite important. For example, if you would like physicians in attendance, first thing in the morning might work better than during or at the end of the day,” he said.

Holding monthly patient care meetings with all the disciplines involved in wound care is another excellent way to encourage dialogue and to stimulate brainstorming of the various therapeutic options toward accomplishing the goal of healing wounds in a timely fashion.

The literature supports the value of these multi-disciplinary meetings.

For example, ordering physicians, nurses, physical therapists, dietitians, and assistive personnel can be on hand to collaborate with staff in these ways:

  • Discussing current treatment approaches
  • Making suggestions in the care
  • Ensuring that everyone is using the same terminology

Ensure everyone knows how to use new products

Wollheim pointed out that switching from one brand of a wound care product to another may involve different sets of instructions for their use.

“Anytime you change brands, you need to make sure all staff members know how to use the new product,” he said. “This may require an in service to make sure that all the staff is on the same page and using the new product correctly as the manufacturer intended to achieve the best outcomes for patients.”

A good example is utilizing negative pressure wound care (NPWC) systems.

Whichever wound care systems clinicians use, they are striving to achieve the same goals — decreasing the exudate that may have bacteria or proteolytic enzymes in it, decompressing the capillaries to increase the blood flow to the wound, and stimulating cell division. However, the devices are not the same and can vary in the following ways:

  • Some units are disposable.
  • Some units are used over open wounds, over full thickness wounds, on top of split thickness skin grafts, or on top of closed surgical wounds.
  • Some units employ irrigation.
  • Some units use different methods of aspiration, such as continuous, intermittent, and intermittent variable.

Approaches to preventing and managing pressure injuries continue to advance based on research. By understanding evidence-based concepts and implementing them in your practice, you can enhance your clinical knowledge of pressure injuries and improve outcomes for patients.

Take our engaging, evidence-based Wound Care Certification Courses for nurses, registered dietitians, physical therapists, and more professionals. Choose the format that suits you and get access to tools to help you ace your exam.

Editor’s Note: This post was originally published in April 2020 and has been updated with new content.

Carole Jakucs, MSN, RN, PHN, CDCES

Carole Jakucs, MSN, RN, PHN, CDCES, is a freelance writer and diabetes educator. Her background in nursing includes tenures in healthcare management and as a care provider. She has worked in med/surg/telemetry, a pediatric emergency department and college health.