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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Wednesday, March 27, 2019

Woo's Pick, March 2019

The March 2019 CE/CME article, Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries, is an excellent review of evidence that attempts to differentiate pressure injury from what is commonly known as 'skin failure' in patients who are critically ill or approaching death. During critical medical crises and at life's end, a failing heart may not be able to maintain adequate perfusion to vital organs, leading to multiorgan failure, including the skin. Skin changes are inevitable when metabolic demand outstrips supply of oxygen and vital nutrients. The early signs that herald skin breakdown were initially described by Kennedy and further validated by the SCALE expert panel. Skin breakdown may be unavoidable when prevention strategies are deemed futile or even precarious. 

While skin failure and pressure injuries are separate entities, they are intimately linked and share many common risk factors. In a retrospective study of data from 2,062 patients at the end of life,1 a history of pressure injuries, cancer, incontinence, activity/mobility, and skin circulation were predictive of pressure injuries.

Another retrospective cohort study2 evaluated 766 patients in 9 intensive care units of 2 university hospitals. The overall pressure injury incidence was 18.7%. The likelihood of having a pressure injury increased by 7.8 times in palliative care and 2.3 times in patients who were between 60 and 84 years old. The chances also increased 10% for each day of hospitalization and 1.5% for each point of the Nursing Activities Score.

In an examination of 154 patients receiving palliative care, all had evidence of pressure injuries during hospitalization.3 Interestingly, improvement of pressure injuries was observed in 74% of patients; specifically in 75% of those with sacral ulcers, 50% of those with heel ulcers, and over 80% of those with ischial pressure injuries. These findings suggest that pressure injuries in palliative care patients can be improved with appropriate care regardless of whether skin failure exists.

Last, the risk factors for pressure injury were explored in patients who had a life expectancy of 6 months or fewer and received home palliative care.4 The prevalence of pressure injuries was 13.1%. Pressure injuries were more common among patients who were female, of older age, and those with a low body mass index, low Braden score, and poor physical functioning. Patients with more than one caregiver at home were also at higher risk, perhaps because of inconsistency in care. 

The relationships among pressure injuries, SCALE, terminal ulcers, and skin failure are complex and requires further evaluation. If you'd like to weigh in on this thorny issue, please take the Advances in Skin & Wound Care Survey on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries, available until June 30, 2019 at



1. Li HL, Lin SW, Hwang YT. Using nursing information and data mining to explore the factors that predict pressure injuries for patients at the end of life. Comput Inform Nurs 2019;37(3):133-41. 

2. Strazzieri-Pulido KC, S González CV, Nogueira PC, Padilha KG, G Santos VLC. Pressure injuries in critical patients: incidence, patient-associated factors, and nursing workload. J Nurs Manag 2019;27(2):301-10.

3. Dincer M, Doger C, Tas SS, Karakaya D. An analysis of patients in palliative care with pressure injuries. Niger J Clin Pract 2018;21(4):484-91.

4. Artico M, Dante A, D'Angelo D, et al. Prevalence, incidence and associated factors of pressure ulcers in home palliative care patients: a retrospective chart review. Palliat Med 2018;32(1):299-307.