Pressure Injuries and Wound Care
NPIAP staging, Braden scale, and wound healing
Pressure injury stages (NPIAP)
| Stage 1 | Intact skin with non-blanchable redness (may look different in darker skin: check warmth, firmness, pain) |
| Stage 2 | Partial-thickness loss with exposed dermis: shallow pink-red wound bed or intact/ruptured serum blister. No slough |
| Stage 3 | Full-thickness skin loss; fat may be visible; slough or eschar may be present; undermining or tunneling possible. No bone, tendon or muscle |
| Stage 4 | Full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone |
| Unstageable | Base hidden by slough or eschar. Leave stable, dry eschar on heels in place |
| Deep tissue pressure injury | Intact or non-intact skin with persistent non-blanchable deep red, maroon or purple color, or a blood-filled blister |
Also: medical device–related injuries (staged) and mucosal membrane injuries (not staged). They're called "stages", not "types". Don't reverse-stage: a healing stage 3 stays "healing stage 3".
Braden scale
Six areas: sensory perception, moisture, activity, mobility, nutrition (each 1–4), friction and shear (1–3). Total 6–23; lower score = higher risk.
| 15–18 | Mild risk |
| 13–14 | Moderate risk |
| 10–12 | High risk |
| ≤9 | Very high risk |
Prevention
- Reposition regularly (commonly every 2 h in bed), 30° side-lying tilt.
- HOB ≤30° unless contraindicated (reduces shear); lift, don't drag.
- Float heels; pressure-redistributing mattress; no donut cushions.
- Keep skin clean and dry; barrier cream for incontinence.
- Don't massage red bony areas.
- Protein and calories (dietitian); hydration.
Wound basics
- Healing: primary intention (edges closed), secondary (left open, granulates), tertiary (delayed closure).
- Drainage: serous (clear), sanguineous (bloody), serosanguineous (pink), purulent (pus: infection).
- Infection: redness, warmth, swelling, pain, odor, purulent drainage, fever, usually days 3–7.
- Wound vac (negative pressure): keep the seal; don't leave it off for long periods (follow policy); stop and notify for bright red bleeding.
Dehiscence and evisceration
Dehiscence: wound edges separate. Evisceration: organs protrude (emergency).
Stay with the patient; call for help; cover with sterile gauze moistened with sterile saline; low Fowler's with knees bent; nothing by mouth; monitor for shock.
Stay with the patient; call for help; cover with sterile gauze moistened with sterile saline; low Fowler's with knees bent; nothing by mouth; monitor for shock.