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Pressure Injuries and the Aging Skin

Abigail R. Powers

James Madison University, School of Nursing

NSG 325 Concepts of Aging

Professor Garman

November 15, 2020

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Abstract

This article reviews the integumentary system and the development of pressure injuries or

bedsores. Normal skin anatomy is analyzed including the layers of the skin as well as the normal

age-related skin changes such as decreased adipose tissue, elastin, collagen and sensory

perception. Pressure ulcers are described for their development and reasons for establishment

which includes ischemia or insufficient blood flow to skin. Locations for bedsore development

are recognized involving boney prominences on the body. In addition, risk factors are defined.

Age, underlying illnesses, skin health, and mobility are just a few examples of risk factors for

pressure ulcers. Assessment tools and preventive measures are explained such as the Braden

Scale for Pressure Sore Risk©. Moreover, nutritional preventive methods are cited and

encompass the importance of protein, micronutrients, and water for wound healing as well as

overall skin integrity. Pressure injury types and their characteristics are identified as well as

treatment options.

Keywords: pressure injuries, Braden Scale for Pressure Sore Risk©, integumentary

system
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Pressure Injuries and the Aging Skin

A 2016 Sweden study found that 39 out of 183 patients had developed heel pressure

injuries during the care delivery chain of which they observed five ambulance stations, two

emergency departments, and 16 wards at two hospitals. The study found that 21% of patients

developed a pressure injury with 47-64 percent being at risk to develop one. Moreover, the

inquiry discovered that not enough preventive measures were used resulting in pressure ulcer

development (Muntlin, Engström, Gunningberg, et al., 2016).

The skin is made up of three layers including the epidermis, dermis, and subcutaneous

layer. The top layer or epidermis is the thinnest layer and lacks a blood supply. The dermis is the

second layer of skin and varies in thickness. For example, the dermis is thicker on the soles and

palms. The subcutaneous layer is made up of fat and contains veins and arteries just above it.

When this blood supply is compromised pressure ulcers develop (Crawford & Yoost, 2020, p.

600).

Geriatric patients are more susceptible to pressure injuries due to the normal

physiological age-related skin changes. Within these changes, the epidermis thins as well as the

adipose tissue or fat decreases. In addition, the skin losses its elasticity due to the decrease in

elastin and collagen which can be seen through wrinkles. Moreover, the hydration of the skin

decreases. With all these skin changes and potential decrease in mobility as well as a stagnant

lifestyle, geriatric patients are at greatest risk for pressure ulcers (Zhang & Duan, 2018).

Pressure injuries or bedsores develop when ischemia occurs. Ischemia is the lack of

sufficient blood flow. This can occur when pressure from an outer source, such as a chair, pushes

against a bone. For example, when sitting body weight is pushing the body downward and the

chair is creating more pressure toward the bone in the opposite direction. This makes a sandwich
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effect with the blood supply creating ischemia. Moreover, after sitting for too long pain can be

felt causing a position change which then restores blood supply. However, when a geriatric

patient has limited sensory perception, an age-related skin change, pain will not be felt resulting

in continued pressure and insufficient blood flow (Crawford & Yoost, 2020, p. 597).

A 2017 study was conducted to identify the risk factors of pressure injuries within the

critical care unit. The research was based on previous studies that were published in the

databases of CINAHL (EBSCOhost), the Cochrane Library (Wilson), Dissertations & Theses

Global (ProQuest), PubMed (National Library of Medicine), and Scopus. Of those databases, a

total of 1,753 sources were analyzed. In addition, a diagram was constructed illustrating the risk

factors of pressure ulcer development and their relationship to each other. For example, poor

nutrition as well as low albumin, correlates with decreased perfusion due to lack of needed

nutrients. In addition, risk factors include older age, medications, diabetes, moisture, immobility,

poor perfusion, overall skin health, infection, increased body temperature, and chronic wounds

(Alderden, Rondinelli, Pepper, et al., 2017).

The Braden Scale for Pressure Sore Risk©, is an assessment tool used to identify an

individual’s risk for a pressure ulcer. The scale assesses moisture, sensory perception, activity,

mobility, nutrition, as well as friction and shear to produce a predicted bedsore analysis. Points

are summed together to form a total score. Therefore, a score of less than or equal to 18 indicates

a risk of pressure injury development ranging from mild, moderate, high, or severe (Kennerly,

Boss, Yap, et al., 2015).

Pressure ulcers mainly develop on areas of the body that contain boney prominences.

This includes locations on the body such as the hips, between the knees, heels, shoulders, sacrum

or coccyx, ischial tuberosity or buttocks, and elbows. In addition, bedsores can develop when a
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medical device causes rubbing or pressure such as a nasal cannula. However, preventive

measures and devices can be used to cushion boney prominences, provide comfort, and distribute

pressure evenly (McInnes, Jammali-Blasi, Bell-Syer, et al., 2018).

The nurse or healthcare team can prevent bedsore development through simple tasks.

These tasks can include using a draw sheet when transferring or lifting a patient and having lift

assists when needed such as for a larger patient. Moreover, it is vital that the nurse ensure proper

water intake as well as food consumption for adequate skin integrity. The nurse can also turn a

patient every two hours, clean a patient correctly and make sure there is no moisture, as well as

clean an incontinent patient in a timely manner.

It is found that there is a correlation between diet and nutritional status to pressure ulcer

development. For example, individuals that are malnourished impede the natural phases of

wound healing. In other words, malnourished patients have longer inflammatory responses and

shorter wound healing in the proliferative and maturation phases of which actual skin regrowth is

occurring. In Japan a study was conducted of which 58.7 percent of individuals 65 and older that

had pressure injuries also were malnourished. It is also found that taking an oral protein

supplement decreases a patient’s risk of bedsore formation by 25 percent. Therefore, increased

protein intake has been linked to improved wound healing. Moreover, protein and vitamins A

and C as well as zinc are vital nutrients for wound healing. Hydration as well as proper fluid

intake are also essential to skin integrity and skin repair. Fluid allows for blood flow to injured

tissues and preventives bedsores (Saghaleini, Dehghan, Shadvar, et al., 2018).

Pressure ulcers have difference stages based on the wounds thickness or depth. Stages

include stage one, two, three, and four. A stage one pressure injury is characterized by red,

purple, or blue skin discoloration of which the skin is still in intact. However, the skin is non-
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blanchable meaning that when touched the skin does not change color. In addition, a stage two

bedsore is characterized as a partial-thickness wound. In this stage, the skin has breakage and

looks like a blister. A stage three pressure ulcer is a full thickness wound of which the wound

extends through the epidermis, dermis, and subcutaneous layers. Moreover, a stage four bedsore

is identified as extending through the skin layers and into the muscle, tendons, ligaments, or

bone. Most times, muscle and bone are exposed creating an increased risk for injection or sepsis

(McInnes, Jammali-Blasi, Bell-Syer, et al., 2018).

Various treatments options for pressure ulcers are available ranging from debridement of

which dead tissue is removed, dressings, as well as wound drainage systems such as negative

pressure wound therapy (NPWT) and vacuum assisted closure (VAC). Debridement can take

several forms including sharp, mechanical, enzymatic, autolytic, and biological. Sharp

debridement involves using a scalpel to remove dead tissue whereas mechanical uses dressings

to remove tissue. In addition, enzymatic uses enzymes through topical agents and autolytic uses

enzymes through the body to get rid of necrotic skin. Moreover, biologic debridement is the use

of maggots or larvae for dead tissue removal (Crawford & Yoost, 2020, p.161) Moreover,

NPWT and VAC systems are used to remove excessive drainage (Agarwal, Kukrele, Sharma,

2019).

In the United States, approximately 1 to 3 million individuals develop pressure ulcers

each year with 60,000 people dying due to complications of a bedsores (Saghaleini, Dehghan,

Shadvar, et al., 2018). Therefore, it is vital to recognize the risk factors, causes, preventive

measures, treatment options, and stages to pressure injuries. In addition, it is important to provide

healthy overall skin integrity and understand the normal age-related skin changes to geriatric

patients.
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Citations and References

Agarwal, P., Kukrele, R., & Sharma, D. (2019). Vacuum assisted closure (VAC)/negative

pressure wound therapy (NPWT) for difficult wounds: A review. Journal of clinical

orthopaedics and trauma, 10(5), 845–848. https://doi.org/10.1016/j.jcot.2019.06.015

Alderden, J., Rondinelli, J., Pepper, G., Cummins, M., & Whitney, J. (2017). Risk factors for

pressure injuries among critical care patients: A systematic review. International journal of

nursing studies, 71, 97–114. https://doi.org/10.1016/j.ijnurstu.2017.03.012

Yoost, B. L., & Crawford, L. R. (2020). Fundamentals of nursing: Active learning for

collaborative practice. St. Louis, MO: Elsevier.

Kennerly, S., Boss, L., Yap, T. L., Batchelor-Murphy, M., Horn, S. D., Barrett, R., & Bergstrom,

N. (2015). Utility of Braden Scale Nutrition Subscale Ratings as an Indicator of Dietary

Intake and Weight Outcomes among Nursing Home Residents at Risk for Pressure Ulcers.

Healthcare (Basel, Switzerland), 3(4), 879–897. https://doi.org/10.3390/healthcare3040879

McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E., & Leung, V. (2018). Support surfaces for

treating pressure ulcers. The Cochrane database of systematic reviews, 10(10), CD009490.

https://doi.org/10.1002/14651858.CD009490.pub2

Muntlin Athlin, Å., Engström, M., Gunningberg, L., & Bååth, C. (2016). Heel pressure ulcer,

prevention and predictors during the care delivery chain - when and where to take action? A

descriptive and explorative study. Scandinavian journal of trauma, resuscitation and

emergency medicine, 24(1), 134. https://doi.org/10.1186/s13049-016-0326-0

Saghaleini, S. H., Dehghan, K., Shadvar, K., Sanaie, S., Mahmoodpoor, A., & Ostadi, Z. (2018).

Pressure Ulcer and Nutrition. Indian journal of critical care medicine : peer-reviewed,
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official publication of Indian Society of Critical Care Medicine, 22(4), 283–289.

https://doi.org/10.4103/ijccm.IJCCM_277_17

Zhang, S., & Duan, E. (2018). Fighting against Skin Aging: The Way from Bench to Bedside.

Cell transplantation, 27(5), 729–738. https://doi.org/10.1177/0963689717725755