Pressure injuries are one of the most persistent and costly challenges in healthcare, but those best placed to prevent them are often the people closest to the patient: nurses.
Empowering nurses to act quickly
Nurses’ proximity to patients gives them unparalleled insight into subtle changes that could signal early skin breakdown. They notice when a patient’s skin integrity is changing - yet organisational barriers can sometimes delay timely intervention.
“Empowering the people at the bedside to make changes as quickly as possible is key,” says Sarah Sage, Clinical Nurse Consultant in Wound Management at the Royal Melbourne Hospital.
“In large hospitals, there are so many variations of beds, mattresses and cushions that it can be difficult for staff to know if they’re using the optimal combination. We need to make sure the nurses have both the permission and the resources to make those adjustments right there at the bedside, without waiting for multiple approvals.”
Michelle Barakat-Johnson, Professor of Wound Care and Skin Integrity at the University of Sydney and Sydney Local Health District, agrees: “Nurses are the first line of defence. They perform daily skin assessments, anticipate risks and advocate for the right equipment and care plans. Their role in early identification and ongoing management is absolutely crucial.”
Identifying pressure injuries
Pressure injuries are classified from Stage 1 to 41,2, then Suspected Deep Tissue Injury and Unstageable:
- Stage 1: Non-blanchable erythema of intact skin - an early warning sign.
- Stage 2: Partial-thickness loss of dermis, presenting as an abrasion or blister.
- Stage 3: Full-thickness skin loss with subcutaneous fat visible.
- Stage 4: Full-thickness skin and tissue loss with exposed bone, tendon, or muscle.
- Unstageable: Full-thickness tissue loss with the base obscured by slough or eschar.
- Suspected Deep-Tissue Injury: Purple or maroon intact skin or blood filled blister.
In Australia, Stage 2 pressure injuries account for most treatment and hospital length of stay costs, so stopping the progression of Stage 1 pressure injuries could result in big cost-savings for the healthcare system3.
Use this step-by-step guide to conduct a blanch test on Stage 1 pressure injuries and help prevent them from progressing.
- Ensure good lighting, wash your hands and wear gloves if required.
- Identify skin that is reddened, discoloured or, in darkly pigmented skin, has localised warmth, oedema, or changes in tissue consistency such as bogginess or firmness.
- Use your index finger to gently press on the reddened or area of concern and observe the response.
- Blanchable erythema: The area turns white under pressure and returns to red within a few seconds after releasing.
- Indicates good blood flow and no tissue damage.
- Non-blanchable erythema: The area remains red and does not turn white under pressure.
- Suggests damage to the microcirculation and may indicate a Stage 1 pressure injury.
- Blanchable erythema: The area turns white under pressure and returns to red within a few seconds after releasing.
- Pay particular attention to tissue over bony prominences and areas in contact with medical devices.
Early detection: use all the senses
Both experts stress that early detection of pressure injuries requires more than just a visual scan – it’s about using touch, communication and clinical reasoning. “Early identification involves both visual and tactile assessments,” says Professor Barakat-Johnson. “Nurses should look and feel for signs such as boggy or firm areas over bony prominences, and talk to patients about any pain or discomfort they notice.”
For Ms Sage, combining validated tools with clinical intuition is key. “We use a validated risk assessment tool like the Braden Scale,” she explains. “But we add extra questions. For example, have they had a pressure injury before? Do they have a deformity or poorly controlled pain? Do they have a medical device? Even if the overall score isn’t high, we encourage nurses to look at sub-scores and say, ‘Clinically, I think they’re at high risk,’ and act accordingly.”
Take a comprehensive approach
Pressure injury prevention involves4:
- nutrition assessment
- repositioning and offloading, using devices such as heel boots
- skin hygiene
- incontinence management
- prophylactic dressings to reduce pressure and shear
- correctly fitting medical devices
- monitoring
- education and support for the patient
Pressure Injury Treatment Advisory Group
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Download a copy of the Quick Guide to Pressure Injury Management by the Pressure Injury Treatment Advisory Group (PITA).