Why the Shift from Pressure Ulcer to Pressure Injury?

By Jeanne Pettinichi, MSN, RN, CPN, CPEN
Vapotherm Clinical Nurse Educator

Jeanne Pettinichi has 34 years’ experience as a nurse, including 10 years experience as a Clinical Nurse Education Specialist at two Level I Trauma Centers—Children’s National, DC and Cincinnati Children’s.

The views and ideas presented in this blog article are solely those of the author, and the content is not intended to serve as medical advice. Vapotherm does not practice medicine or provide medical services. Practitioners should refer to the full indications for use and operating instructions of any products referenced herein before prescribing them. Jeanne Pettinichi is an employee of Vapotherm.

If you, like me, started your clinical career decades ago, you probably heard the term “pressure ulcer” over and over again. But the term “pressure injury” has become much more prevalent now when discussing wound care and prevention. It even happened that recently, the National Pressure Ulcer Advisory Panel (NPUAP) officially changed their name to National Pressure Injury Advisory Panel (NPIAP).

The word “ulcer” connotes an open sore, while “injury” doesn’t have to. For example, if I have a patient who has a tightly strapped mask on his face and develops redness and swelling along the bridge of his nose, that is a pressure injury. The skin may not be broken at all. By calling these incidences “pressure injuries”, the language we use more accurately describes our patients’ reality.

At the end of the day though, a pressure injury is still a pressure injury, no matter what we call it. One of our biggest responsibilities is to prevent and effectively manage Hospital Acquired Pressure Injuries (HAPIs) as much as possible without compromising patient treatment. To quote the Health Research & Educational Trust: “Interventions that can help prevent or quickly treat pressure injuries can reduce the costs of HAPI care and improve quality of life for those affected.”[1]

Prevention Strategies

I’ve written in depth about some of the ways you can minimize Hospital Acquired Pressure Injuries from noninvasive positive pressure ventilation (NiPPV) interfaces. One of the reasons I focus on NiPPV masks is because they are one of the most common medical devices that lead to pressure injuries.[2] Depending on the study, pressure injuries from NiPPV interfaces occur in 5-30% of patients treated with the device.[2] Some research even shows a frequency of up to 50%. [2] In my experience though, best practices of prevention are universal and include the following:

  • Educate nursing and non-nursing staff about pressure injury prevention and management [3]
  • Standardize skin-care practice and documentation
  • Use valid and reliable risk assessment tools appropriate for your patient population [4]
  • Whenever applicable, ensure the proper sizing and fit of the medical device for the individual patient
  • Whenever applicable, use appropriate skin care products, such as prophylactic dressings
  • Monitor and reassess patients

When Possible, Choose Medical Devices Less Prone to Causing Pressure Injuries

My final comment on prevention strategies may seem obvious, but whenever possible, you should choose a medical device that has been demonstrated to be less likely to result in pressure injuries without compromising patient treatment. This of course is not always feasible, but in the case of NiPPV masks, studies have shown that nasal cannula interfaces are less likely to cause pressure injuries.[5,6] Arguably, Mask-Free NIV would be an attractive alternative to consider here, as it uses a nasal cannula interface and has been shown to have equivalent outcomes to NiPPV in spontaneously breathing patients, including hypercapnic patients.[7,8]

Take an online course on pressure injuries and wound care prevention

[1] Health Research & Educational Trust (HRET)(2017,April). Hospital Acquired Pressure Ulcers/ Injuries (HAPU/I): 2017. Chicago, IL: Health Research & Educational Trust​
[2] Black, J., Alves P, Brindle CT, Dealey C, Santamaria N, Call E, Clark M. Use of wound dressings to enhance prevention of pressure ulcers caused by medical devices. Int Wound J 2013; doi: 10.1111/iwj.12111
[3] Agency for Healthcare Quality and Research (AHRQ). Pressure ulcer toolkit. 2014.https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool7b.html
[4] National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf
[5] Black J, Kalowes P. Medical Device-Related Pressure Ulcers. Chronic Wound Care Management and Research Volume 3; 29 August 2016 Volume 2016:3 Pages 91—99.
[6] Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2018 Jan;103(1):F29-F35. doi: 10.1136/archdischild-2017-313418. Epub 2017 Sep 28.
[7] Lavizarri A, Colnaghi M, Ciuffini F, Veneroni C, Musumeci S, Cortinovis I, Mosca F. “Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity – a randomized clinical noninferiority trial.” JAMA Pediatr. 2016 Aug 8.
[8] Doshi, Pratik et al. High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. Annals of Emergency Medicine, 2018.