Classification of Pressure Injuries Flashcards
A staging system classifies pressure injuries
Pressure injury staging describes the pressure injury depth at the point of
assessment. Thus, once you have staged the pressure injury, this stage endures even
as it heals. Pressure injuries do not progress from a stage 3 to a stage 1; rather, a
stage 3 injury demonstrating signs of healing is described as a healing stage 3
pressure injury.
Stage 1 Pressure Injury
Nonblanchable erythema of intact skin
Intact skin with a localized area of nonblanchable erythema, which
may appear differently in darkly pigmented skin (Fig. 48.4A).
Presence of blanchable erythema or changes in sensation,
temperature, or firmness may precede visual changes. Color
changes do not include purple or maroon discoloration; these may
indicate deep tissue pressure injury.
Stage 2 Pressure Injury
Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present
as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result
from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe
moisture-associated skin damage (MASD), including incontinenceassociated
dermatitis (IAD), intertriginous dermatitis (ITD), medical
adhesive–related skin injury (MARSI), or traumatic wounds (skin
tears, burns, abrasions).
Stage 3 Pressure Injury
Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer
and granulation tissue and epibole (rolled wound edges) are often
present (see Fig. 48.4C). Slough and/or eschar may be visible. The
depth of tissue damage varies by anatomical location; areas of
significant adiposity can develop in deep wounds. Undermining
and tunneling may occur. Fascia, muscle, tendon, ligament,
cartilage, and/or bone are not exposed. If slough or eschar obscures
the extent of tissue loss, this is an Unstageable Pressure Injury.
Subcutaneous fat may be visible but bone, tendon and muscle not visible in stage 3.
Stage 4 Pressure Injury
Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable
fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer (see
Fig. 48.4D). Slough and/or eschar may be visible. Epibole (rolled
edges), undermining, and/or tunneling often occur. Depth varies by
anatomical location. If slough or eschar obscures the extent of tissue
loss this is an Unstageable Pressure Injury.
Deep-Tissue Pressure Injury
Persistent nonblanchable deep red, maroon, or
purple discoloration
Intact or nonintact skin with localized area of persistent
nonblanchable deep red, maroon, purple discoloration or epidermal
separation revealing a dark wound bed or blood-filled blister (see
Fig. 48.4E). Pain and temperature change often precede skin color
changes. Discoloration may appear differently in darkly pigmented
skin. This injury results from intense and/or prolonged pressure
and shear forces at the bone-muscle interface. The wound may
evolve rapidly to reveal the actual extent of tissue injury or may
resolve without tissue loss. If necrotic tissue, subcutaneous tissue,
granulation tissue, fascia, muscle or other underlying structures are
visible, this indicates a full-thickness pressure injury (Unstageable,
Stage 3, or Stage 4). Do not use Deep-Tissue Pressure Injury to
describe vascular, traumatic, neuropathic, or dermatologic
conditions.
Unstageable Pressure Injury
Obscured full-thickness skin and tissue loss - extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
Other types of wounds
- Laceration - can bleed profusely - if bigger than 5cm in length and inch deep then serious bleeding. May be contaminated with bacteria and has jagged edge.
- Puncture wound - use cotton applicator to determine depth of wound.
- Abrasions - caused by skin rubbing against rough surface but does not cause much bleeding.
Patient may need tetanus vaccine
Colour
- Black
- Soft yellow/white - slough (substance that needs to be removed so that wound can heal). Clean would w non-cytotoxic cleanser e.g. saline as this won’t kill fibroblasts and healing tissue.
- Red
- Mixed
Wound Drainage
- Serous - Clear, watery plasma
- Purulent - Thick, yellow, green, tan, or brown - indicates an infection which needs to be resolved for wound to heel- conduct head to toe assessment, vital signs and check lab tests especially CBC (complete blood cell count) and WBC.
- Serosanguineous - Pale, pink watery - mixture of serous and blood
- Sanguineous - Bright red; indicates active bleeding - this is blood
1 gram of drainage = 1ml volume of drainage …measure by weighing dry gauze and then weighing when damp with drainage.
Wound Drainage Device
Assess amount of drainage, colour, consistence, surrounding dressing, tubing. If sudden increase (could be haemorrhaging/bleeding) or decrease (may indicate blocked drain) in drainage device. Measure drainage from drainage device.
- Jackson-Pratt drainage device
- Hemobag
Would Complications
Dehisced wound - occurs when incision fails to heal properly and layers of skin and tissues separate. can occur after sudden movement - vomiting, coughing, moving up in bed. Dehiscence is the partial or total separation of wound layers. Risk factors: infection, poor nutritional status and obesity.
With total separation of wound layers, evisceration (protrusion of visceral organs
through a wound opening) occurs. This is a surgical emergency …place sterile gauze in sterile normal saline and place over sight. Place patient on MPO.
Hematoma (post surgery)- localised collection of blood underneath tissue - swelling, change in colour, warmth. Near a artery/vein is dangerous as can put pressure there.
Haemorrhage (bleeding) - risk is great after 28 hours of surgery.
Infection - in surgical wound infection develops around 4-5th day post surgery. And traumatic wounds 2-3 days. Not only local but can be systemic.
Types of Wound Healing
Primary intention - occurs when wounds have little tissue loss. Skin edges are approximated closed and risk of infection is low. e.g. surgical incision. Healing occurs quickly with minimal scar formation
Secondary Intention - wound edges are not approximated and healing is by granulation scar tissue (red moist tissue w new blood vessels which means healing is taking place and should not be removed) formation and contraction of wound edges. Takes longer to heal and thus change of infection is greater. e.g. burns, pressure injury, laceration.
Partial thickness round repair - done on partial thickness wounds that are shallow and loss of epidermis/dermis. Healed by regeneration as epidermis regenerates.
Full thickness repair - healed by scar formation and scar may be severe as deeper structures don’t regenerate e.g. stage 4 ulcers - extend into dermis hence need for full thickness thickness. Has 4 stages:
1) Hemostasis - injured blood vessels constrict and platelets gather to stop bleeding. Clots form fibrin matrix that starts cellular repair.
2) Inflammatory - In the inflammatory stage damaged tissue and mast cells secrete histamine, resulting
in vasodilation of surrounding capillaries and movement/migration of serum and
white blood cells into the damaged tissues. Leukocytes (white blood cells) reach a wound within a few hours. The primaryacting
white blood cell is the neutrophil, which begins to ingest bacteria and small
debris. The second important leukocyte is the monocyte, which transforms into
macrophages. The macrophages are the “garbage cells” that clean a wound of
bacteria, dead cells, and debris by phagocytosis. Macrophages continue the process
of clearing a wound of debris and release growth factors that aract fibroblasts, the
cells that synthesize collagen (connective tissue). Collagen appears as early as the
second day and is the main component of scar tissue.
3) Proliferative - phase are the filling of a wound with granulation tissue, wound contraction, and
wound resurfacing by epithelialization
4) Maturation - Collagen fibers undergo
remodeling or reorganization before assuming their normal appearance.
Scar tissue - few pigmented cells and lighter colour than normal skin.
