Pressure Injuries: prevention, treatment, and complications - Part II

Velozo, Bruna Cristina; Hong, Michelle Venâncio; Bernardo, Larissa Cassiano; Castro, Meire Cristina Novelli e; Contreras-Ruiz, Jose; Abbade, Luciana Patricia Fernandes

doi:10.1016/j.abd.2025.501215

person Bruna Cristina Velozo

Design · planning of the study · literature survey · drafting · editing of the manuscript · critical review of the literature · critical review of the manuscript · approval of the final version of the manuscript

schoolNursing Department, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil

0000-0002-3334-8578

person Michelle Venâncio Hong

Design · planning of the study · literature survey · drafting · editing of the manuscript critical review of the literature · critical review of the manuscript · approval of the final version of the manuscript

schoolNursing Department, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil

0000-0002-4684-2196

person Larissa Cassiano Bernardo

Design · planning of the study · literature survey · drafting · editing of the manuscript · critical review of the literature · critical review of the manuscript · Approval of the final version of the manuscript

schoolNursing Department, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil

0000-0002-2465-8144

person Meire Cristina Novelli e Castro

Design · planning of the study · literature survey · drafting · editing of the manuscript · critical review of the literature · critical review of the manuscript · approval of the final version of the manuscript

schoolNursing Department, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil

0000-0002-0590-4127

person Jose Contreras-Ruiz

Design · planning of the study · literature survey · drafting · editing of the manuscript · critical review of the literature · critical review of the manuscript · approval of the final version of the manuscript

schoolCentro Dermatológico Polanco Los Cabos, Los Cabos, MexicoschoolHospital General Dr. Manuel Gea González, Ciudad de México, MexicoschoolDepartment of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil

0000-0002-5788-9854

person Luciana Patricia Fernandes Abbade *

schoolDepartment of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil

0000-0002-0334-2079

person* Corresponding author.
E-mail address:fernandes.abbade@unesp.br (L.P. Fernandes Abbade)

Conflicts of interest

None declared.

Editor

Hiram Larangeira de Almeida Jr.

Preventive Measures	Recommendations
Skin Assessment and Care	• Daily skin assessment in areas of bony prominences and medical devices, paying attention to areas of erythema, oedema, or changes in skin temperature or texture.
	• Keep the skin clean and hydrated, avoiding the use of alkaline soaps.
	• Avoid rubbing and vigorously massaging skin at risk of pressure injuries, especially over bony prominences.⁷
	• Use a barrier cream or barrier spray, especially in areas with persistent moisture exposure, such as the diaper area in incontinent patients.

Preventive Dressingsa	• Recommended for all patients at risk of PIs, especially those in intensive care units, in areas of bony prominences.
Preventive Dressingsa	• Use silicone and multilayer foam dressings, especially on the sacral area and heels.

Repositioning	• The exact interval for repositioning is not known and is done empirically.
	• When repositioning, consider individual factors such as skin tolerance, overall medical condition, treatment goals, comfort, and pain.
	• Repositioning every two hours has been reported in some studies to contribute to a reduction of up to 25% in the incidence of PIs³⁷,⁴⁴ having a specific team (turning team) to perform repositioning has been shown to reduce this risk by 51%.⁴⁴
	• On the heels, a foam pillow or cushion should be used to distribute the weight of the leg along the calf without applying pressure to the Achilles tendon and the popliteal vein.
	• Manual techniques and equipment, such as rotation mattresses and sliding sheets, assist in proper repositioning, reducing friction during movement, and helping with comfort.
	• When repositioning, consider individual factors such as skin tolerance, overall medical condition, treatment goals, comfort, and pain.

Head of bedb	• Ideally, the head of the bed should be kept at the lowest elevation possible, consistent with clinical conditions and other constraints.
Head of bedb	• When elevation of the head of the bed is necessary, precautions should be taken to avoid patient sliding or migration.

Surfaces (bed and mattress)	• When choosing the best surface, individual patient characteristics should be considered, including the risk of PIs.⁴⁰
	• Choose mattresses that allow a minimum thickness of 2.5 cm between the patient’s body and the rigid surface of the bed.
	• Evaluate mattress density to ensure the patient does not “sink” into the mattress.
	• Recommended mattresses: pneumatic mattresses (air-alternating mattresses) offer better cost-effectiveness compared to foam mattresses (pyramid-shaped or “egg crate” type).⁵²

Nutrition	• Nutritional status is a significant factor in preventing PIs, as both malnourished lean and obese patients face a heightened risk of developing them due to compromised tissue integrity and reduced healing capacity.⁵³
	• Screen all patients for nutritional risk using a validated tool, such as the Malnutrition Universal Screening Tool (MUST).⁴⁹
	• Nutritionist assessment to develop an appropriate plan for at-risk patients.
	• For neonates and children with or at risk of PIs who have inadequate oral intake, consider enriched foods, age-appropriate nutritional supplements, or enteral or parenteral nutritional support.
	• Supplements, in general, still have low evidence in prevention and require studies on special diets (e.g., high-protein, vegetarian).⁵¹

Summary ‒ PIs classification	Exudate level	Treatment recommendations (remove and treat the cause)	Dressings, products and recommended measures
Stage 1 PI
Non-blanchable erythema, intact skin	Absent	Avoid friction in the area when applying moisturizing creams and during bathing. Focus on pressure relief in the area and daily reassessment.	• Barrier film/cream when required;
Non-blanchable erythema, intact skin	Absent		• Five-layer foam dressings with or without silicone adhesive.
Stage 2 PI
Superficial skin loss involving the epidermis/upper dermis.	Intact blister	Keep intact, protecting the area with an appropriate dressing. Depending on the blister's location, size, and characteristics, aspiration with an aseptic technique may be performed to prevent rupture and exposure to infection.	• Foam dressings with or without silicone adhesive; • Collagen, or acrylic dressings
Superficial skin loss involving the epidermis/upper dermis.	Broken skin with minimal exudate	Promote treatment with a moist environment but with balance. Pay attention to signs of infection and the color of the exudate.	• Foam dressings with or without silicone adhesive • Hydrocolloid, acrylic dressing, collagen/composite dressing
Stage 3 PI
Full-thickness damage to the subcutaneous tissue, but not reaching the muscle fascia	Low/moderate exudate	Maintain moist treatment. Assess for necrotic tissue requiring debridement and stabilize viable tissues. Manage bacterial balance/biofilm.	• Hydrogela if autolytic debridement is required. • Antimicrobial gels such as polyhexamethylene biguanidea if local infection. • Absorbent dressings for moderate exudation, such as foam dressings, gelling fibreb
	High exsudate	Increased exudate may be indicative of infection. Assess for necrotic tissue requiring debridement and stabilize viable tissues. Manage bacterial balance/biofilm. Protect edges with barrier cream products.	• Superabsorbent dressings, such as polymer foams, silver dressings (e.g., gelling fiber or foam dressings with silverb) • Alginate dressingsb • Collagen dressingsb • Negative pressure wound therapy.
Stage 4 PI
Total loss of skin thickness affecting muscle and/or bone	Low/moderate exudate	Maintain granulation tissue. Assess for necrotic tissue requiring debridement. Manage bacterial balance/biofilm. Be attentive to osteomyelitis (exposed or palpable bone).	• Absorbent dressings for moderate exudation, such as foam dressings, gelling fibreb • Absorbent dressings for infection: foam dressings with silverb, gelling fiber dressings with silverb, PHMB gela, cadexomer iodinea
Total loss of skin thickness affecting muscle and/or bone	High exudate	Increased exudate may indicate of infection ‒ be attentive to osteomyelitis (exposed or palpable bone). Assess for necrotic tissue requiring debridement and stabilize viable tissues. Manage bacterial balance/biofilm. Protect edges with barrier cream products	• High-absorption dressings, such as foams and silver ion dressingsb • Negative pressure wound therapy.
Non-classifiable PI
Any wound completely covered by necrotic tissue with no visualization of the wound bed.	Absent	Facilitate debridement (if the wound has the capacity to heal) or protect (keep the necrotic tissue dry if healing is not the goal of care of the wound is ischemic (DIP stages C). Instrumental debridement if there is adequate blood circulation and the patient is not anticoagulated. Combine debridement methods. Pay attention to patient pain.	• Below knee - aim to keep the wound dry until vascular assessment is determined. Apply povidone iodine 10%a to the wound bed. Keep the wound dry until the vascular assessment is determined (exclude ischemic injury); after that, it is possible to perform surgical debridement • Above knee ‒ consider an antimicrobial gel (polyhexamethylene biguanide)a to aid in autolytic debridement • In case of mild bleeding, use calcium and sodium alginate dressinga for hemostasis, or a hemostatic product. In case of severe bleeding seek help from a trained surgeon.
Deep Tissue PI
Purplish, bruised, or blood-filled blister lesion in an area of bony prominence	Absent	Avoid friction in the area when applying moisturizers and during bathing. Focus on relieving pressure in the area and perform daily reassessment.	• Skin protectors • Barrier/film cream • Silicone foam dressings
	Superficial rupture with exudate (may occur days after the onset of the pressure injury)	Maintain moist treatment. Assess the necrotic tissue and proceed with caution when debriding. In cases of deep ischemia, avoid debridement in areas with compromised circulation; If necessary, do so gently and superficially, preserving viable tissue	Depending on the exudate: • Silicone foams for atraumatic coverage, or • Absorbent dressings for moderate exudation, such as gelling fiber and foam dressings.
	Blood blister	Inspect injury for improvement or deterioration and monitor capillary return; Aspiration with an aseptic technique may be performed to prevent rupture and exposure to infection	• Five-layer silicone foam dressing • Absorbent dressing if there is heavy exudate
Medical Device-Related PI
It has the shape of the device and follows the same classification as above, and the same treatment according to depth and location.	Exudate varies according to the stage of involvement and the phase of healing.	Control moisture. Focus on the ease of application and removal of the dressing. Allow assessment of skin condition. Evaluate for infection/biofilm.	• Treatment according to the location and stage of the pressure injury. • Combine wound coverage with protection of the medical device. • Include the use of cushions, coverings, or protective materials that not only prevent additional pressure in the area but also allow for easy and safe access to the device, minimizing the risk of contamination and infection
PI on mucous membranes
Typically caused by medical devices on mucous membranes in areas such as the vaginal, rectal, urethral, and oral cavities.	Absent or exudative	Non-blanchable erythema is not visible on mucous membranes. Check for fluid accumulation. Reposition and adjust medical devices regularly to prevent prolonged pressure on a single point. Remove the device as soon as clinically possible. Assess for fungal/yeast infection.	Mucosa: • Carefully clean the lesion with water or saline and solutions appropriate for mucous membranes, avoiding irritants. • Apply solutions appropriate for the area. • Use topical/systemic antimicrobials as needed. Skin: • Superficial area on the nostril: keep the area protected and consider using gentle white paraffin. • If there is deeper tissue loss and exudate needs to be controlled, consider using a silicone foam dressing. • Necrotic tissue: keep intact and protect with a barrier dressing.

[TFN1] ^a
According to a systematic review,³⁷ foam dressings have been shown to reduce the incidence of pressure injuries by 30%.

[TFN2] ^b
Elevating the head of the bed creates higher interface pressures between the skin and the bed surface at the sacrococcygeal area. Mechanically ventilated patients, when at a 45 ° elevation, have almost a 50% higher risk of pressure injuries compared to a 30 ° elevation.⁴⁶