Integ. Unit 5 Pressure Injuries Flashcards
What is the Incidence of Pressure Injury/Ulcer?
- 2x as likely in critical care units
- Increased likelihood with SCI
- Increaesd likelihood with acute pediatric, cardiovascular and neonatal patients
What is the Pathophysiology of Pressure Injuries?
- Result of mechanical injury to the skin
- Proposed underlying mechanism of injury:
-Ischemia
-Impaired lymphatic flow
-Reperfusion
-Deformation of tissues
What is the Clinical Presentation for Pressure Injuries?
- Local Hyperemia (redness) observed within 30 minutes of pressure
- Ischemia ~ 2-6 hrs of continuous pressure
- Necrosis ~6 hrs after continuous pressure
- Ulceration ~2 weeks after necrosis has been oberved
According to the NPUAP
What is stage 1 of Pressure Injury?
Superficial
Nonblanchable erythema of intact skin
According to the NPUAP
What is stage 2 of Pressure Injury?
Partial-thickness loss with exposed dermis
According to the NPUAP
What is stage 3 of Pressure Injury?
Full thickness skin loss; bone/tendon/muscle NOT exposed
- Evidence of necrotic tissue automattically characterizes the wound as stage 3
According to the NPUAP
What is stage 4 of Pressure Injury?
Full thickness skin and tissue loss; with exposed fascia/bone/tendon/muscle
According to the NPUAP
What is the Unstageable Pressure Injury?
Obscured full-thickness skin and tissue loss; base of wound covered with slough or eschar
- Until wound is debrided, the full depth cannot be ascertained
According to the NPUAP
What is the Suspected Deep Tissue Injury Pressure Injury?
Persistent non-blanchable deep red, maroon or purple discoloration
What are the Risk factors for Pressure Injuries?
- Immobility
- Inactivity
- Sensory loss
- Shear/friction forces
What is the Braden Scale?
This is a Risk Assessment
- Subscales consistent of sensory perception, moisture, activity, mobility, nutrition, friction and shear
- Lower scores = Bad (lower function and higher risk for ulcer development)
What is the Norton Scale?
Risk Assessment Tool
- Subscales consist of physical condition, mental state, activity, mobility and incontinence
- Low risk = 17-20 out of 20
What Interventions can be done for Pressure Injuries?
Pressure Relief:
- PRAFOs (Protection Relief Ankle Foot Orthosis), Weightshifting/Repositioning
Pressure redistribution support surface
- Roho cushions
- Air mattresses
- Pressure mapping systems
Care for moisture prone areas
- Prevent “maceration”
- Barrier creams
Reduce friction/shearing forces
How can a patient control pressure injuries?
- Change positions or shift your weight at least every 2 hours while lying down and every 15 minutes while sitting. Do not lay on a body surface that is damaged or still red from prior positioning.
- Use positioning devices and cushions as instructed.
- Keep heels off the bed.
- Avoid pressure over bony prominences.
- Keep head of bed elevated as little as possible.
- Sit with good posture.
- When moving, avoid dragging your skin. Lift your body or have help to move instead.
What are the proper steps to take care of your skin?
- Perform daily skin checks
- Wash with mild soap and water. Pat your skin dry.
- Protect your skin from wetness using a moisture barrier and/or incontinence pads as needed.
- Prevent dry skin with moisturizing lotion.
- Take care of your ulcer
- Wear bandages as instructed.
- Cleanse your wound as instructed.
- Avoid pressure on wound
When should you notify your clinician about a wound?
- You notice your wound is getting larger, is draining more, or has a foul odor.
- You have increased pain or swelling.
- You notice an area of redness that does not go away.
- You detect a new wound
