8.4 Wound Healing, Skin Integrity & Pressure Injury Prevention

Wound Healing, Skin Integrity & Pressure Injury Prevention

Domain 3, Task 1 lists indications, contraindications, and precautions associated with wound management and maintaining skin integrity as a preparatory-method knowledge statement, and names stage of wound healing and prevention and management of pressure ulcers as its two examples. Occupational therapists rarely perform sharp debridement, but they decide on every shift whether a transfer method, an orthosis wearing schedule, a physical agent modality, or a wheelchair cushion is safe for the skin in front of them. Items in this area almost always reward the response that removes the cause of the tissue damage rather than the one that treats the visible wound.

1. The Four Phases of Wound Healing

Healing is a continuum, and the phase determines what activity demand the tissue can tolerate.

Depth matters as much as phase. A partial-thickness wound involves the epidermis and part of the dermis, retains the dermal appendages that supply new epithelium, resurfaces by epithelialization, and is typically painful because nerve endings survive. A full-thickness wound extends through the dermis into subcutaneous tissue, must close by granulation and contraction or grafting, carries a far higher contracture risk, and may be relatively insensate at its center.

2. Pressure Injury Staging (NPIAP, 2016 revision)

In 2016 the National Pressure Injury Advisory Panel replaced the term pressure ulcer with pressure injury, switched from Roman to Arabic numerals, and removed the word suspected from deep tissue injury.

Three traps recur on the exam:

• Never reverse-stage. A healing Stage 4 injury does not become a Stage 3 and then a Stage 2. Granulation and scar do not regenerate the lost fascia or muscle. It is documented as a healing Stage 4.
• Blanching is unreliable in darkly pigmented skin. Stage 1 may not look red at all. Compare the site to surrounding tissue for changes in color, temperature, firmness, boggy or taut texture, and pain.
• Stable, dry, adherent eschar on an ischemic heel is left alone. It is acting as the body's biological cover; it is not softened or removed unless erythema, fluctuance, or drainage signals infection.

3. Risk Screening: The Braden Scale

The Braden Scale scores six subscales. Five — sensory perception, moisture, activity, mobility, and nutrition — are scored 1 to 4. Friction and shear is scored 1 to 3 only. The total therefore ranges from 6 to 23, and a lower score means higher risk.

The subscale breakdown, not just the total, drives the OT plan: a low mobility subscale points to repositioning and seating, a low moisture subscale points to incontinence management, and a low friction and shear subscale points squarely at transfer technique and bed positioning.

4. Where Pressure Injuries Form

The seated client is the highest-pressure case in occupational therapy: sitting concentrates body weight onto the small surface area of the ischial tuberosities.

5. The Prevention Protocol

• Reposition in bed roughly every two hours. The 2019 international guideline frames this as individualized to tissue tolerance, activity level, and the support surface rather than as a fixed clock interval, but two hours remains the working default.
• Seated pressure relief approximately every 15 to 30 minutes, held long enough for reperfusion — commonly taught as 30 seconds to 2 minutes. Options are the push-up, the forward lean, the lateral lean, and power tilt or recline for clients who cannot self-relieve.
• Use 30-degree lateral side-lying, not 90 degrees. True side-lying loads the greater trochanter directly.
• Keep the head of bed at 30 degrees or lower unless medically contraindicated (aspiration risk, tube feeding, respiratory distress). Higher elevation slides the torso and shears the sacrum.
• Float the heels. Place a pillow lengthwise under the calf so the heel does not contact the mattress; heel offloading boots are an alternative.
• Never use a ring or donut cushion. It creates a circumferential band of ischemia and venous congestion around the very tissue it is meant to protect.
• Never massage over a bony prominence or a reddened area. It adds mechanical load to already-compromised capillaries.
• Manage moisture. Incontinence-associated dermatitis macerates skin and lowers tolerance; prompt cleansing and barrier products are preventive care, not comfort care.
• Address nutrition and hydration. Inadequate protein and calories stall the proliferative phase; refer to the dietitian.
• Reduce friction and shear in transfers. Lift rather than drag, use a draw sheet or mechanical lift, and teach a slide-board technique that clears the buttocks off the board instead of scraping across it.

6. The Occupational Therapy Role

Seating surface selection is squarely OT's responsibility:

Client education is the durable intervention. For a client with spinal cord injury or any sensory loss, teach a twice-daily visual skin inspection using a long-handled mirror, covering ischial tuberosities, sacrum, trochanters, and heels; teach that redness which does not resolve within about 30 minutes of offloading must be reported; and build the weight shift into an existing routine so it becomes habit rather than homework.

Orthotic wear schedules are a pressure-injury protocol in disguise. Skin is checked at every increment of a graded schedule. Redness persisting more than roughly 20 to 30 minutes after removal means the pressure exceeded tissue tolerance, and the device is relieved or remolded — not merely padded, because adding padding inside a total-contact orthosis raises pressure rather than lowering it.

7. Precautions and Contraindications to Recognize

8. How This Is Tested

Scenario items give you a skin finding and a planned activity, then ask what to do. Work in this order: identify the classification, remove the mechanical cause, then adjust the OT plan. When one option treats the wound surface and another eliminates the pressure, shear, or moisture that produced it, the second option is the answer.