Assessment/Risk Factors for Pressure Injury Development Flashcards
Nutrition
Normal wound healing requires proper nutrition.
Deficiencies in any of the nutrients result in impaired or delayed healin. Physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals zinc and copper. Collagen is a protein formed from amino acids acquired by fibroblasts from protein ingested in
food. Vitamin C is necessary for synthesis of collagen. Vitamin A reduces the negative effects of steroids on wound healing. Trace elements are also necessary. The best measure of nutritional status is prealbumin because it reflects not only what the patient has recently ingested but also what the body has absorbed, digested, and metabolized!!!! serum albumin most frequently measured, best measurement of nutritional status is prealbumin as it reflects what the patient has ingested and what the body has absorbed, digested and metabolised.
- Impaired Sensory Perception- Patients with altered sensory perception for pain and pressure are more at risk for impaired skin integrity.
- Impaired Mobility- major risk to skin formation of Pressure injury is increased.
Moisture
The presence and duration of moisture on the skin increases the risk of pressure
injury. Moisture reduces the resistance of the skin to other physical factors such as
pressure, friction, or shear. Prolonged moisture softens skin, making it more
susceptible to damage.
Friction
effect of rubbing or resistance - a force that opposed movement. Unlike shear injuries, friction injuries affect the epidermis or
top layer of the skin (superficial skin loss).A friction injury occurs in
patients who are restless, in those who have uncontrollable movements such as
spastic conditions, and in those whose skin is dragged rather than lifted from the bed
surface during position changes or transfer to a stretcher. This type of injury should
not be classified as a pressure injury
Shear force
is the sliding movement of skin and subcutaneous tissue while the
underlying muscle and bone are stationary (Bryant, 2016). Shear force occurs when
the head of the bed is elevated and the sliding of the skeleton starts but the skin is
fixed because of friction with the bed (Fig. 48.3). It also occurs when transferring a
patient from bed to stretcher when a patient’s skin is pulled across the bed. The damage that shear
causes occurs at the deeper fascial level of the tissues over the bony prominence
(Pieper, 2016). The underlying tissue capillaries are stretched and angulated by the
shear force. As a result, necrosis occurs deep within the tissue layers.
Alteration in Level of Consciousness
Patients who are comatose, confused or disoriented; those who have expressive
aphasia or the inability to verbalize; and those with changing levels of consciousness
are unable to protect themselves from pressure injury. Also patients who are
confused or disoriented may be able to feel pressure but are not always able to
understand how to relieve it or communicate their discomfort. A patient in a coma
cannot perceive pressure and is unable to move voluntarily to relieve pressure.
Psychological assessment: Body imagine
self conscious because of wound especially when odour and drainage.
Dark Skin
essential to inspect skin …natural/halogen light recommended to look at skin not florescent as could interfere with accurate assessment.
Pulse Oximetry
Pulse oximetry measurement affects wound healing because oxygen is essential to healing process. ability to perfuse tissues w adequate amount of oxygenated blood critical.
Impaired Sensory Perception
Patients with altered sensory perception for pain and pressure are more at risk for impaired skin integrity.
Impaired Mobility
major risk to skin formation of Pressure injury is increased.
Pressure Intensity
A classic research study identified capillary closing pressure as the minimal amount of pressure required to collapse a capillary (e.g., when the pressure exceeds the normal capillary pressure range of 15 to 32 mm Hg).
Therefore, when the pressure applied over a capillary exceeds the normal capillary
pressure and the vessel is occluded for a prolonged period of time, tissue ischemia
can occur. If the patient has reduced sensation and cannot respond to the discomfort
of the ischemia, tissue ischemia and tissue death result. After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, the skin turns red. The effect of this redness is vasodilation (blood
vessel expansion), called hyperemia (redness). You assess an area of hyperemia by
pressing a finger over the affected area. If it blanches (turns lighter in color) and the
erythema returns when you remove your finger, the hyperemia is transient and is an
attempt to overcome the ischemic episode, thus called blanchable hyperemia.
However, if the erythematous area does not blanch (nonblanchableerythema) when
you apply pressure, deep tissue damage is probable.Blanching occurs when the normal red tones of the light-skinned patient are absent.
Pressure Duration
Low pressure over a prolonged period and high-intensity pressure over a short
period are two concerns related to duration of pressure. Both types of pressure cause
tissue damage.
Tissue Tolerance
The ability of tissue to sustain and to endure pressure depends on the integrity of the tissue and the
supporting structures. The extrinsic factors of shear, friction, and moisture affect the
ability of the skin to tolerate pressure: the greater the degree to which the factors of
shear, friction, and moisture are present, the more susceptible the skin will be to
damage from pressure. The second factor related to tissue tolerance is the ability of
the underlying skin structures (blood vessels, collagen) to help redistribute pressure.
Systemic factors such as poor nutrition, aging, hydration status, and low blood
pressure affect the tolerance of the tissue to externally applied pressure.
Risk Assessment Tool for Pressure Injuries- Braden Scale
Sensory perception - ability to respond to pressure related discomfort
Moisture - degree to exposure
Activity - degree of physical activity
Mobility - ability to change snd control body position
Nutrition - usual food intake pattern
Friction/shear
score ranges from 6 to 23; a lower total score indicates a higher risk
for pressure injury development
Wound Assessment
Measure length and width of wound, tunnelling (depth) and undermining (under the tissue, erosion of wound)
