Pressure Injuries (Pressure Sores)

What are pressure injuries?

Pressure injuries are areas of damaged skin or tissue. They happen when something presses on the skin for too long, reducing blood flow and oxygen to the area. This can cause the skin to break down and form sores. 

Children can get pressure injuries if they stay in the same position for a long time or when medical equipment, like braces or casts, puts pressure on their skin. 

Symptoms of pressure injuries 

Pressure injuries start with small changes in the skin. They may look different depending on your child’s skin tone.

Early signs and symptoms

In the beginning, pressure injuries may look red, discolored, or like dark patches on the skin. The area may feel warm, firm, tender, or swollen.

For children with lighter skin tones, pressing on the area may cause it to turn pale or white. It should go back to its normal color quickly. If the color does not return, this could be a sign of damage.

For children with dark skin tones, redness may not be visible. Instead, the areas may look slightly darker, purple, or blue. 

Later signs and symptoms 

As the sores get worse, the skin may break open, forming blisters or open sores. These sores can be painful and may leak fluid.

In severe cases, pressure injuries can go deeper, damaging layers of skin, muscle, and even bone. Sometimes the wound is covered by dead tissue or yellowish material. This makes it hard to see how deep the injury is.

Deep tissue injuries 

Some pressure injuries do not break the skin. But they look purple or like a dark bruise. This can mean deeper tissues are damaged. These injuries need treatment right away. 

Causes of pressure injuries

Pressure injuries happen when skin and tissues are damaged by pressure, stretching, pulling, or rubbing that reduces blood flow.

Common causes include:

• Staying in the same position for too long, such as lying in bed or sitting in a chair or wheelchair  
• Medical equipment pressing against the skin, such as:
  • Oxygen masks or nasal tubes (cannula)
  • Blood pressure cuffs
  • Surgical wraps 
  • Feeding tubes
  • IV lines or catheters
  • Urinary catheters
  • Braces, casts, or other devices
• Rubbing against a surface or sliding down in a bed or chair 

Risk factors for pressure injuries 

Patients are more likely to get pressure injuries if they:

• Have a medical device
• Cannot move or change positions easily
• Have delicate or dry skin
• Cannot feel pain
• Have damp skin
• Have poor nutrition
• Have low body weight
• Take certain medicines 
• Have medical conditions that affect the immune system, nerves, or blood vessels

Diagnosis of pressure injuries

Health care providers diagnose pressure injuries during a physical exam. They will:

• Look for symptoms of pressure injuries
• Feel the area to see if it is warm, cool, firm, or tender
• Ask if the area feels sore or painful

Stages of pressure injuries

If a pressure injury is found, the health care provider will put it into 1 of 4 stages. These stages are based on how severe the pressure injury is. Stage 1 is the least severe. Stage 4 is the most severe.

• Stage 1: Red or discolored skin that is not broken. The area may feel warm, swollen, or tender.
• Stage 2: The skin has broken open. The sore may look like a blister or wound.
• Stage 3: The sore is deeper and affects layers of tissue under the skin. The wound bed has a yellowish tissue (slough).
• Stage 4: The sore is deep and may reach muscles, bones, or tendons.

Treatment of pressure injuries

Treatment of pressure injuries depends on the severity of the sore. The main goal is to remove or offload the pressure from the affected area. Always follow your care team’s instructions for how to keep the area clean and help the skin heal. 

Ways to help treat pressure injuries include:

Relieve pressure

• Assess medical devices to make sure they are not causing skin damage. Change the device position or use pads to protect the skin when possible.
• Reposition your child often so they do not stay in the same position for too long.
• Use cushions, foam pads, or special mattresses to reduce pressure on the sore.

Remove damaged tissue

• In deeper sores (Stage 3 or Stage 4), the health care provider may need to remove dead or damaged tissue. This procedure is called debridement.

Surgery for severe sores

• If the sore is deep and does not heal with other treatments, surgery may be needed to help close the wound or to treat infection. 

How to prevent pressure injuries

Check skin daily

Pressure injuries can be prevented by checking the skin every day.

• Take off clothing, including socks, pajamas, underwear, diapers, and anything else that covers the skin. 
• Check underneath all devices. Look at places where braces, casts, feeding tubes, or other devices touch the skin. 
• Examine bony areas. This includes:
  • Back of the head (this is the most common place for pressure injuries in children)
  • Shoulders
  • Elbows
  • Hips
  • Buttocks and tailbone
  • Feet (heels, ankles, and bottoms)

Change positions often

Have your child change positions as much as possible. If your child needs to stay in bed, help them change positions at least every 2 hours. Children in a wheelchair should adjust their position at least every hour.

Cushions or special mattresses can help take pressure off bony areas. In some cases, the care team might recommend preventive dressings or bandages to take pressure off bony parts of the body.

Take care of the skin

• Keep skin clean and dry: Wash gently with mild soap. Pat dry. Change diapers or undergarments right away if they get wet. 
• Moisturize dry skin: Use a moisturizer recommended by your care team.
• Avoid irritation: Do not rub, scratch, or scrub the skin. Treat skin gently to keep skin from breaking open. Keep clothes and sheets smooth and wrinkle-free.
• Watch for things that might injure the skin: Avoid tight clothes or clothes with buttons or zippers that press into the skin. Make sure that wheelchairs and medical devices fit well and do not rub the skin.

Eat healthy and drink water

• Eat foods with protein, vitamins, and minerals to help the skin stay healthy and heal faster.
• Drink enough water to keep the skin hydrated.

Prognosis for pressure injuries

The prognosis for pressure injuries depends on how severe the sore is and how quickly it is treated.

• Stage 1 and Stage 2 sores: These sores are mild and usually heal within a few days or weeks with proper care. 
• Stage 3 and Stage 4 sores: These sores are deeper in the skin. They may affect muscles, tendons, or bones. Healing can take weeks to months if treated with proper care.
• Complications: Severe sores can lead to infections, including sepsis or bone infection (osteomyelitis). These require immediate medical attention.

With the right care, most pressure injuries heal completely, and the skin returns to normal. Severe sores may leave scars or cause long-term damage, especially if they affect deeper tissues. 

When to call your care team 

Contact your care team if you notice any of the following:

• Skin changes such as change in color, pain, swelling, or warmth
• Signs of infection, such as fever, pus, bad smell, or redness that worsens or spreads  
• Sore that gets worse or does not improve with home care

Let your care team know if you have trouble positioning your child or if you notice any issues with how medical equipment or devices fit.

Questions to ask your care team

• Is my child at risk for pressure injuries?
• What are the early signs of pressure injuries I should look for in my child?
• How can I tell if a pressure injury is getting worse?
• What parts of the body should I check for pressure injuries?
• What medications or creams might help my child’s skin heal faster?
• What is the best way to prevent pressure injuries?

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