Localised damage to the skin due to pressure in combination with a shearing force.
Usually occur over a bony prominence - but may be related to a medical device/other objects
| Stage | Observation |
|---|---|
| Stage I | non-blanchable |
| Stage II | partial thickness |
| Stage III | full thickness skin loss |
| Stage IV | full thickness tissue loss |
| Injury | suspected deep tissue injury |
| Unstageable | full thickness skin or tissue loss |
Causes/Factors
- Reduced mobility
- Nutritional deficiency
- Older age
- Poor vascular supply to skin and soft tissues (Diabetes Mellitus, peripheral vascular disease)
Locations
Investigations
Are not used to make the diagnosis but may be required if the diagnosis is uncertain and to exclude complications
- Wound swabs only if infection suspected
- ABPI
- HbA1c
Management
- Nutritional risk assessment
- Pressure redistributing devices
- Debriding the wound if indicated
- Regular turns in bed
- Encourage mobility
- Antibiotics look up local guidelines/discuss with micro
- Appropriate wound dressings
Complications/red Flags
- Pain
- Infection
- Increased mortality 5x in older patients - longer hospital stays