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geriatrics.pressure-injury.core.v1

Pressure injury (staging and management)

general_internal_medicinechronicsubacutegeriatricadultinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Prevention-led dossier: one rich 7-step regimen axis (Braden risk assessment → prevention bundle → stage-based wound care → continuous offloading → infection management → NPWT/surgical flap → goals-of-care/palliative). Manifest repointed to prisma/seed/manifests/symptom.falls.v1.ts as a placeholder (shared immobility/frailty upstream driver + CGA/skin-assessment spine); dedicated geriatrics.pressure-injury manifest, problem-package, and atoms authored in the deepening pass. No Braden Scale calculator in clinical-tools-registry.ts — Braden subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear) and risk tiers are encoded in prose (RISK_STRATIFICATION phase + Step 1 of the regimen axis); only generic calc.qsofa / calc.news2 used for the sepsis overlay. No RxNorm CUIs assigned — the axis is overwhelmingly non-pharmacologic (repositioning, support surfaces, dressings, debridement, NPWT, surgery, nutrition support); the two pharmacologic entries (systemic antibiotics, multimodal analgesia) are intentionally class-level and culture/agent-directed, so rxcui is deferred to RxNav Stage-A validation. Bayesian likelihood ratios for mimic discrimination (pressure vs arterial/venous/diabetic/IAD) deferred to the deepening pass.

Entry points (4)

  • symptom
    Skin breakdown / non-blanchable erythema / blister over sacrum, heel, ischium, trochanter, occiput (NPIAP/EPUAP 2019)
    skin_breakdown_over_bony_prominence
  • problem_list
    Immobility / bedbound / ICU / spinal cord injury / advanced frailty — at-risk skin (NPIAP/EPUAP 2019)
    immobility_high_risk
  • history
    Braden Scale <=18 (mild) / <=12 (high) on admission or routine reassessment (Braden & Bergstrom 1987)
    braden_score_at_risk
  • imaging
    Skin injury under medical device (mask, tube, collar, splint, oximetry probe) — device-related pressure injury (NPIAP/EPUAP 2019)
    device_related_skin_injury

Required inputs (11)

  • agerequired
    demographic • used at FRAME
    Geriatric skin fragility, thin dermis, reduced perfusion raise risk; informs goals-of-care framing at end of life
  • mobility_statusrequired
    history • used at CONTEXT
    Immobility / bed- or chair-bound state is the dominant modifiable driver; sets repositioning need (NPIAP/EPUAP 2019)
  • braden_subscalesrequired
    history • used at RISK_STRATIFICATION
    Sensory perception, moisture, activity, mobility, nutrition, friction/shear — Braden risk stratification + clinical judgement (Braden & Bergstrom 1987)
  • wound_location_and_appearancerequired
    symptom • used at INITIAL_WORKUP
    Anatomic site (sacrum/heel/ischium/trochanter) + tissue visible drives NPIAP stage assignment (NPIAP 2016 staging revision)
  • continence_statusrequired
    history • used at CONTEXT
    Incontinence-associated dermatitis is a distinct mimic and a pressure-injury accelerant; drives barrier/moisture plan (NPIAP/EPUAP 2019)
  • nutrition_statusrequired
    history • used at INITIAL_WORKUP
    Malnutrition impairs healing; protein/energy and micronutrient optimisation is a core bundle element (NPIAP/EPUAP 2019)
  • perfusion_vascular_statusrequired
    history • used at CONTEXT
    Peripheral arterial disease/ischemic limb changes debridement safety and distinguishes arterial ulcer mimic (NPIAP/EPUAP 2019)
  • goals_of_carerequired
    history • used at CONTEXT
    Palliative / end-of-life context (Kennedy terminal ulcer) shifts to comfort-focused wound care (NPIAP/EPUAP 2019)
  • temperature
    vital • used at RED_FLAGS
    Fever flags spreading/systemic wound infection or sepsis from infected pressure injury
  • albumin
    lab • used at INITIAL_WORKUP
    Nutritional/inflammatory marker trended with prealbumin; supports malnutrition screen (NPIAP/EPUAP 2019)
  • current_meds
    medication • used at CONTEXT
    Corticosteroids/immunosuppression/sedatives impair healing and mobility; vasopressors worsen perfusion in ICU

12-phase flow (12)

  1. 1FRAME
    Confirm scope: localized skin/soft-tissue injury from sustained pressure +/- shear over a bony prominence or under a device; orient prevention-led vs established-injury management; clarify whether goals are curative or comfort/palliative (NPIAP/EPUAP 2019)
    inputs: age, goals_of_care
    advance: Pressure etiology plausible and curative-vs-palliative frame set (NPIAP/EPUAP 2019)
  2. 2ENTRY
    Capture trigger: visible skin breakdown over a bony prominence, at-risk immobile/ICU/SCI/frail patient, Braden at-risk score, or device-related skin injury (NPIAP/EPUAP 2019)
    inputs: age, mobility_status
    advance: Entry trigger documented (NPIAP/EPUAP 2019)
  3. 3CONTEXT
    Characterise drivers: immobility/activity, continence/moisture, nutrition, perfusion/vascular disease, sensory loss/SCI, ICU/vasopressor exposure, sedation, medical devices, terminal-illness/goals-of-care, prior pressure injury (NPIAP/EPUAP 2019)
    inputs: mobility_status, continence_status, perfusion_vascular_status, goals_of_care, current_meds
    advance: Modifiable and non-modifiable risk drivers characterised (NPIAP/EPUAP 2019)
  4. 4RED_FLAGS
    Screen for sepsis from an infected pressure injury, necrotizing soft-tissue infection (crepitus, rapidly spreading, disproportionate pain, bullae), suspected osteomyelitis (probe-to-bone, exposed bone in Stage 4), and rapidly evolving deep tissue pressure injury (NPIAP/EPUAP 2019)
    inputs: temperature, wound_location_and_appearance
    actions: calc.qsofa, calc.news2
    advance: No emergent infection/sepsis or escalated appropriately (NPIAP/EPUAP 2019)
  5. 5INITIAL_WORKUP
    Comprehensive geriatric / multidomain assessment (workup.cga) for risk + nutrition + functional status; full-body structured skin assessment; NPIAP staging of every lesion; baseline CBC, CMP/metabolic, albumin/prealbumin, CRP; UA if incontinence/IAD overlap (NPIAP/EPUAP 2019)
    inputs: wound_location_and_appearance, nutrition_status, albumin
    actions: workup.cga, panel.cbc, panel.metabolic, panel.cmp, panel.ua
    advance: CGA done; every lesion NPIAP-staged and measured; baseline labs sent (NPIAP/EPUAP 2019)
  6. 6BRANCHING_WORKUP
    Stage-driven branching: Unstageable with non-viable cover → plan debridement EXCEPT stable dry intact heel eschar (leave in place); suspected osteomyelitis → probe-to-bone + MRI + deep tissue culture/bone biopsy (NOT superficial swab); spreading erythema → assess cellulitis; non-healing Stage 3/4 → surgical consult; atypical/chronic non-healing >3 months → biopsy for Marjolin ulcer (NPIAP/EPUAP 2019)
    inputs: wound_location_and_appearance, perfusion_vascular_status
    actions: workup.cga
    advance: Branch diagnostics queued by stage and complication risk (NPIAP/EPUAP 2019)
  7. 7DIFFERENTIAL
    Distinguish pressure injury from mimics by location/etiology: incontinence-associated/moisture dermatitis (perineal, no bony prominence, diffuse), arterial ulcer (distal, dry, painful, absent pulses), venous ulcer (gaiter area, exudative), diabetic neuropathic foot ulcer (plantar pressure points), skin tear, calciphylaxis, pyoderma gangrenosum; also classify pressure-injury type (Stage 1–4 / Unstageable / DTPI / device-related / mucosal) (NPIAP 2016 staging revision)
    inputs: wound_location_and_appearance, perfusion_vascular_status
    advance: Pressure etiology confirmed vs mimic excluded and lesion type assigned (NPIAP 2016 staging revision)
  8. 8RISK_STRATIFICATION
    Braden Scale total + subscale pattern (sensory perception, moisture, activity, mobility, nutrition, friction/shear) with structured clinical judgement: not at risk (>=19), at risk (15–18), moderate (13–14), high (10–12), very high (<=9); identify high-risk cohorts — ICU, SCI, advanced frailty, terminal illness, vasopressor-dependent, prior pressure injury; severity by deepest NPIAP stage; sepsis/NSTI overlay via qSOFA/NEWS2 (Braden & Bergstrom 1987; NPIAP/EPUAP 2019)
    inputs: braden_subscales, wound_location_and_appearance
    actions: calc.qsofa, calc.news2
    advance: Braden risk tier + NPIAP stage assigned; high-risk cohort flagged; prevention intensity set (Braden & Bergstrom 1987)
  9. 9TREATMENT
    PREVENTION bundle for all at-risk (structured skin assessment, individualised repositioning, pressure-redistributing support surface, heel offload/float, moisture/IAD barrier, nutrition/protein optimisation, prophylactic sacral/heel dressings, HOB <=30 deg unless contraindicated). MANAGEMENT for established injury: stage-based wound bed prep (TIME — debride non-viable tissue [autolytic/enzymatic/sharp/surgical] EXCEPT stable dry heel eschar/ischemic limb; control infection; moisture-balanced dressing by stage/exudate — Stage 2 hydrocolloid/foam, exudative Stage 3/4 alginate/foam, dry hydrogel; advance the edge); CONTINUOUS offloading/pressure relief; pain control; protein +/- arginine/micronutrients if Stage >=3 and malnourished; NPWT for selected Stage 3/4; surgical debridement and flap reconstruction for non-healing Stage 3/4; treat infection (deep tissue culture, systemic antibiotics only for spreading cellulitis/systemic infection/osteomyelitis); palliative/comfort wound care when goals are end-of-life (NPIAP/EPUAP 2019)
    inputs: braden_subscales, wound_location_and_appearance, nutrition_status, goals_of_care
    advance: Prevention bundle in place for at-risk skin and stage-based management plan initiated with continuous offloading (NPIAP/EPUAP 2019)
  10. 10DISPOSITION
    Inpatient: admit/keep for sepsis, NSTI, osteomyelitis, surgical debridement/flap, or uncontrolled Stage 3/4; specialty wound care / WOCN, plastic surgery, infectious disease, dietitian, palliative care consults as indicated. Outpatient: home/SNF wound care with support-surface provision, caregiver education, and home health/wound clinic follow-up; hospice for terminal/comfort-focused (NPIAP/EPUAP 2019)
    inputs: goals_of_care
    advance: Care setting confirmed and multidisciplinary referrals placed (NPIAP/EPUAP 2019)
  11. 11MONITORING
    Wound measurement + PUSH tool at baseline then weekly (and at any deterioration); reassess Braden each shift in ICU / daily acute inpatient / each home or clinic visit; trend nutrition markers (albumin/prealbumin, intake, weight) q1–2 weeks; surveillance for local-to-spreading infection, evolving DTPI, undermining/tunneling; verify offloading and repositioning adherence (NPIAP/EPUAP 2019)
    inputs: wound_location_and_appearance, braden_subscales, albumin
    actions: panel.cbc, panel.metabolic
    advance: Wound stable/improving on serial PUSH, no new injury, infection surveillance current (NPIAP/EPUAP 2019)
  12. 12FOLLOWUP
    Care-transition skin handoff (POA documentation, stage, support surface continuity), caregiver/patient education on repositioning and skin checks, recurrence-prevention plan, dietitian follow-up, wound clinic / WOCN review, advance care planning and goals-of-care revisited at each transition; quality/never-event reconciliation for hospital-acquired Stage 3/4/Unstageable/DTPI (NPIAP/EPUAP 2019)
    inputs: goals_of_care
    advance: Skin handoff documented, education delivered, follow-up and ACP scheduled (NPIAP/EPUAP 2019)