Pressure Injury Prevention/Staging, Urinary/Fecal Incontinence & Frailty Assessment

Pressure Injury Prevention/Staging, Urinary/Fecal Incontinence & Frailty Assessment

Pressure Injury Prevention and NPIAP Staging

A pressure injury is defined by the National Pressure Injury Advisory Panel (NPIAP) as localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device. Pressure injuries result from intense, prolonged pressure or pressure combined with shear. In older adults, age-related skin changes—including dermal thinning, flattened dermo-epidermal junction, decreased subcutaneous fat, and reduced vascularity—greatly increase tissue vulnerability.

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NPIAP Pressure Injury Staging System

1. Stage 1 Pressure Injury: Non-Blanchable Erythema

• Clinical Presentation: Intact skin with a localized area of non-blanchable erythema (redness that does not turn white when pressed). In darkly pigmented skin, erythema may not be obvious; look for changes in skin temperature, tissue firmness (induration), or localized pain.

2. Stage 2 Pressure Injury: Partial-Thickness Skin Loss

• Clinical Presentation: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister. Adipose (fat) tissue and deeper anatomical structures are not visible. Granulation tissue, slough, and eschar are absent.

3. Stage 3 Pressure Injury: Full-Thickness Skin Loss

• Clinical Presentation: Full-thickness loss of skin in which subcutaneous adipose (fat) tissue is visible within the ulcer. Granulation tissue and epibole (rolled wound edges) are frequently present. Slough or eschar may be visible. Deep tissue structures—such as fascia, muscle, tendon, ligament, cartilage, and bone—are NOT exposed. Undermining and tunneling may occur.

4. Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss

• Clinical Presentation: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and eschar may be present. Epibole, undermining, and tunneling are common. There is a high clinical risk of osteomyelitis and systemic sepsis.

5. Unstageable Pressure Injury: Obscured Full-Thickness Tissue Loss

• Clinical Presentation: Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 injury will be revealed. Stable, dry, adherent, intact eschar on the heels should not be softened or debrided.

6. Deep Tissue Pressure Injury (DTPI)

• Clinical Presentation: Intact or non-intact skin with localized, persistent non-blanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.

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The Braden Scale for Predicting Pressure Injury Risk

The Braden Scale is a validated clinical risk assessment tool evaluated upon admission and periodically thereafter. It assesses six subscales: Sensory Perception (1-4), Moisture (1-4), Activity (1-4), Mobility (1-4), Nutrition (1-4), and Friction and Shear (1-3).

• Total score range: 6 to 23. Lower scores indicate higher risk.
• Score $\le$12 indicates HIGH RISK (Score 15-18 = mild risk; 13-14 = moderate risk; 10-12 = high risk; $\le$9 = severe/very high risk).
• Preventative Protocols for High Risk ($\le$12): Scheduled Q2H repositioning, pressure-redistribution mattress overlays, heel offloading boots, barrier creams for moisture management, and protein-enriched nutritional supplementation (1.2 to 1.5 g protein/kg/day).

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Urinary Incontinence (UI) Staging and Clinical Management

Urinary incontinence is not a normal consequence of aging. It affects up to 50% of community-dwelling older adults and carries severe psychosocial and physical consequences.

Reversible Causes (The DIAPPERS Mnemonic):

Before diagnosing chronic UI, rule out reversible causes: Delirium, Infection (UTI), Atrophic vaginitis, Pharmaceuticals, Psychological, Excessive urine output, Restricted mobility, and Stool impaction.

Chronic Urinary Incontinence Types:

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Fecal Incontinence Assessment

Fecal incontinence is the involuntary passage of stool. The most common cause in older adults is fecal impaction with overflow diarrhea, where liquid stool leaks around a firm, impacted fecal mass in the rectum. Clinical management requires digital rectal examination (DRE), manual disimpaction if present, followed by a regular bowel regimen (osmotic laxatives like polyethylene glycol, fiber supplementation, and scheduled toileting after meals).

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Frailty Assessment: The Fried Frailty Phenotype

Frailty is a vulnerable biological state resulting from age-related decline in physiological reserve across multiple organ systems, compromising the body's ability to withstand acute stressors.

The 5 Operational Criteria of the Fried Phenotype:

1. Unintentional Weight Loss: Loss of $\ge$10 pounds (or $\ge$5% of body weight) in the preceding 12 months.
2. Self-Reported Exhaustion: Self-reported exhaustion on the CES-D depression scale ("I felt that everything I did was an effort").
3. Low Physical Activity Level: Low weekly energy expenditure (<383 kcal/week for men; <270 kcal/week for women).
4. Slowness (Slow Gait Speed): Standardized walking time over a 15-foot distance exceeding sex- and height-adjusted thresholds.
5. Weakness (Reduced Grip Strength): Dominant hand grip strength measured by dynamometer in the lowest 20th percentile.

Clinical Scoring & Categorization:

• 0 Criteria: Robust (Non-frail)
• 1 or 2 Criteria: Pre-Frail (High risk of progressing to frailty)
• $\ge$3 Criteria: Frail (High risk of falls, hospitalization, disability, surgical complications, and mortality)

Clinical Interventions for Frailty:

Frailty management requires a multidisciplinary approach: prescribing resistance exercise and physical therapy, providing high-protein nutritional supplementation (1.2 to 1.5 g/kg/day), correcting Vitamin D deficiency, aggressively deprescribing PIMs, and conducting advance care planning.