In May, the world celebrates nurses and their contributions to healthcare. In some countries, it is a week-long event that ends on May 12, Florence Nightingale’s birthday. In other countries, it is a month-long celebration. It is an ideal time to reflect on how Florence Nightingale linked nurses to pressure injuries (PIs). Her quote from Notes on Nursing is something we see cited frequently: “If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed sore, it is generally the fault not of the disease, but of the nursing.”1,2

However, not everyone is familiar with the remainder of this popular quote. The additional sentences contextualize nursing practice within the system in which the nurse is providing care:1–3 “By this I do not mean that the nurse is always to blame. Bad sanitary, bad architectural, and bad administrative arrangements often make it impossible to nurse.”1,2 Pressure injuries must be viewed within the context of the health system as we continue to learn more about the physiologic mechanisms associated with their etiology including local ischemia.

In this issue of Advances, several manuscripts from around the world concentrate on PIs. Melnychuk evaluated arterial anatomic aberrancies in persons with terminal skin lesions (Kennedy terminal ulcers, Trombley-Brennan terminal tissue injuries, etc) providing more insights into the etiology and physiologic role of tissue perfusion related to these skin changes. The concept of angiosomes with regional ischemia and their role in terminal ulcers is an important connection for these terminal skin lesions.

This change in etiology is evident in the recent revision of the CMS’ Long Term Care Facility (LTC) Resident Assessment Instrument (RAI) User’s Manual Section M—Skin Conditions, which became effective October 1, 2023.4 The CMS acknowledges that terminal ulcers are not PIs and therefore are not coded in section M (the part of the RAI for PI coding): “Skin changes at the end of life (SCALE), also referred to as Kennedy Terminal Ulcers (KTUs) and skin failure are not primarily caused by pressure and are not coded in section M.”4

The acknowledgment that these terminal ulcers are not PIs is welcome news and we applaud the CMS’ decision to exclude these terminal ulcers from section M of the RAI. However, it is unclear where on the RAI such ulcers should be coded, and additional guidance is needed. Care staff could also benefit from information on how terminal skin changes should be documented in the medical care record. View the videos on Section M for some insights.5

In the continuing education article, Peng and colleagues report risk factors of intraoperative PIs in their sample of 1,728 patients who underwent neurosurgery. They report a PI rate of 1.8% (n = 31), identifying three independent risk factors: lateral or prone body position, a high body mass index, and surgery duration longer than 7.92 hours.

Stiehl’s extensive stage 4 pelvic PI case report (sacrum, ischium, and greater trochanter) documents the consequences of local bacterial damage for over 8 years. Changing the care plan to include low-pressure jet lavage with buffered sodium hypochlorite and monitoring bacterial covert infection with autofluorescence imaging examination was effective in reducing the wound’s bacterial-related autofluorescent positive products.

Further research is warranted to assess PI etiology, prevention, and treatment. Pressure injuries are complex, and ischemia, positioning, body mass index, surgery duration, and bacterial factors result in potential etiologic factors and subsequent complications. The management of PIs requires an interprofessional team to share responsibility for these chronic wounds.

Elizabeth A. Ayello, PhD, MS, RN, CWON, MAPWCA, FAAN

R. Gary Sibbald, MD, MEd, FRCPC (Med Derm), FAAD, MAPWCA, JM

1. Nightingale F. Notes on Nursing; What It Is and Is Not. Fitzpatrick J, Kennedy MS, eds. Philadelphia, PA: Wolters Kluwer; 2019. 2. Ayello EA. From bedsores to pressure injuries: perspectives from Nightingale’s Notes on Nursing. In: Notes on Nursing; What It Is and Is Not. Fitzpatrick J, Kennedy MS, eds. Philadelphia, PA: Wolters Kluwer; 2019, pp 56–61. 3. Ayello EA, Sibbald RG. Pressure injuries: nursing-sensitive indicator or team- and systems-sensitive indicator? Adv Skin Wound Care 2019;32(5):199–200. 4. Centers for Medicare and Medicaid Servies. RAI manual Minimum Data Set 3.0 Resident Assessment Instrument User’s Manual v1.18.11. https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual. Last accessed February 26, 2024. 5. CMS Section M Video. https://www.youtube.com/cmshhsgov. Last accessed February 26, 2024.