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Lecture 4b - Pressure Injuries Flashcards

1
Q

Where do pressure injuries typically develop over?

A

Bony prominences

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2
Q

90% of pressure injuries occur where?

A

sacrum, heel, greater trochanter, ischial tuberosity, and lateral malleolus

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3
Q

What is the most common pressure injury spot for a child?

A

Occiput

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4
Q

Pressure injuries can develop in less than ____ hours.

A

2

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5
Q

Describe the pressure injury periwound.

A
  • Non-blanchable erythema or induration
  • Mottled appearance
  • Necrotic wound bed with ring of inflammation

If incontinence, may have dermatitis.

If reactive hyperemia, may be warm or if there is necrosis/ischemia, it may be cool

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6
Q

Pressure Injury Etiology

A
  1. Pressure
  2. Intracapillary BP
  3. Blood flow to soft tissue obstructed & local tissue ischemia occur & obstructs local lymphatic channels
  4. Higher concentrations of metabolic wastes and acidosis which increases rate of cell death

decrease in fibrinolysis that results in fibrin deposits within capillaries and interstitial space which allow microthrombi to form leading to vessel occlusion

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7
Q

How long does it take after a pressure event for a PI to be visible to us?

A

2-7 days

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8
Q

What is HAPI?

A

Hospital Acquired Pressure Injury: PI that occur during their stay

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9
Q

How long do hospitals have after admission to document a PI on a patient?

A

48 hours

after that is HAPI-period

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10
Q

_ _ _ _ _s becoming the new HAPIs

A

MDRPIs: Medical Device Related PIs

  • Found in 1 in 3 PIs for adults in hospitals
  • # 1 cause of PIs in younger pediatric population in hospital
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11
Q

PI Risk Factors …

A
  • Shear
  • Moisture
  • Impaired Mobility
  • Malnutrition
  • Imapired Sensation
  • Advanced Age
  • Previous PI
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12
Q

Pressure vs. Shear vs. Friction

A
  • Pressure: force applied perpendicular to skin
  • Shear: force applied parallel to skin
  • Friction: 2 surfaces move across one another, force is parallel
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13
Q

What shape are PIs related to shear in?

A

Tear drop appearance

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14
Q

Common reason for shear PI?

A

Having head of bed elevated and sliding down

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15
Q

Urinary incontinence increases risk of PI ____fold

A

Fivefold

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16
Q

PIs are most likely to develop within the 1st ___ weeks of hospitalization, surgery, change in medical condition, or admission

A

Three

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17
Q

What is the 2nd most common risk factor for PI (after decreased mobility)?

A

Malnutrition

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18
Q

Normal sensation vs. impaired sensation

A

Normal: anoxia and chemical irritation cause pain –> you move –> reactive hyperemia making skin red but blanchable

Imapired: no pain –> no movement triggered –> no reactive hyperemia so area isn’t flooded with what it needs

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19
Q

Of pts with PIs, over half are over the age of _____

A

70

because of decreased: elastin, collagen, tissue strength, sebaceous gland secretion, cell replacement rate, dermal vasculature, rete ridges

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20
Q

Regrowth after a PI is only ___% as strong

A

80

haven’t addressed the original cause of the pressure injury

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21
Q

PI Testing/Risk Assessment - name 3

A
  1. Braden Scale
  2. Norton Scale
  3. Gosnell Pressure Score Risk Assessment
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22
Q

What are the 6 subscales of the Braden Scale for Predicting Pressure Sore Risk?

A

1. Mobility
2. Activity
3. Sensory perception
4. Skin moisture
5. Nutrition status
6. Friction & shear

Rate them 1-4

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23
Q

What do the scores on a Braden Scale mean?

A

Can score 6-23, lower = more impaired/higher risk

  • <13 = high risk
  • 13-14 = moderate risk
  • 15-18 = mild risk
  • > 18 = not at risk (18 is the cutoff)

has Braden Q for Pediatrics

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24
Q

What are the 5 subscales for the Norton Risk Assessment Scale?

A
  1. Physical coordination
  2. Mental condition
    3. Activity
    4. Mobility
  3. Incontinence

Rate them 1-4

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25
What do the scores on a Norton Risk Assessment Scale mean?
Can score 5-20, lower score = higher risk for PI * 20 = normal * 16 = critical cutoff, below = at risk for PI * 13 = below this = high risk
26
What are the 5 subscales of the Gosnell Pressure Score Risk Assessment?
1. Mental Status 2. Continence **3. Mobility** **4. Activity** 5. Nutrition
27
What do the scores on the Gosnell Pressure Score Risk Assessment mean?
Can score 5-20, higher = greater risk * 16 = critical cut off *not enough research here*
28
Should you use donut-type devices to assist with positioning?
No, they increase tissue congestion, vascular occlusion, and pressure
29
Who needs to assist patients who are unable to reposition themselves?
Caregivers and healthcare workers
30
For every gram decrease in serum ALB below normal, the risk of PI increases _____fold | serum ALB = albumin
Fourfold
31
What can you use to help with incontinence to prevent PI?
Moisture barriers, frequent checks for wetness and speedy (gentle) clean up
32
T/F: With PI Staging, patients can downgrade and upgrade
False, PIs can "downgrade" but cannot "upgrade" e.g. Once a wound is stage 4, it is always stage 4. It cannot improve to stage 3 as it heals, it is called healing stage 4 e.g. A stage 1 can become stage 2 once skin breaks
33
What stage is this? non-blanchable erythema of intact skin
PI Stage 1
34
What stage is this? Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes
PI Stage 1
35
What color changes may indicate deep tissue pressure injury?
Purple or maroon discoloration
36
What stage is this? Partial-thickness skin loss with exposed dermis
PI Stage 2
37
What stage is this? **Wound bed** is viable, pink or red, moist, may also present as intact or ruptured serum-filled blister
PI Stage 2
38
What stage is this? Adipose is NOT visible & deeper tissues are NOT visible. granulation tissue, slough, and eschar are NOT present
PI Stage 2
39
What stage is this? Commonly results from adverse microclimate and shear in skin over pelvis and shear in the heel
PI Stage 2
40
What is PI stage 2 NOT?
Moisture associated skin damage (MASD): * incontinence associated dermatitis (IAD) * intertriginous dermatitis (ITD) * medical adhesive related skin injury (MARSI) * traumatic wounds (skin tears, burns, abrasions)
41
What stage is this? Full-thickness skin loss
PI Stage 3
42
What stage is this? Full thickness loss, adipose is visible in ulcer & granulation tissue and epibole are OFTEN present Slough and/or eschar MAY be visible
PI Stage 3
43
What stage is this? Depth of tissue damage varies by anatomical location; areas of significant adiposity may develop deep wounds Undermining and tunneling MAY occur Fascia, muscle, tendon, ligament, cartilage and/or bones NOT exposed
PI Stage 3
44
If slough or eschar obscures the extent of tissue loss, this is ______ _______ ______
Unstageable Pressure Injury
45
What stage is this? Full thickness skin and tissue loss
PI Stage 4
46
What stage is this? Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
PI Stage 4
47
What stage is this? Slough and/or eschar are visible Epibole, undermining and/or tunneling OFTEN occur Depth vaires by anatomical position
PI Stage 4
48
What stage is this? Obscured full-thickness skin and tissue loss in which extent of damage within the ulcer cannot be confirmed bc it is obscured by slough or eschar
Unstageable PI
49
What stage is this? If slough or eschar removed, stage 3/4 PI is revealed Stable eschar on heel or ischemic limb should not be softened or removed
Unstageable PI
50
What stage is this? Persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister
Deep Tissue PI
51
What stage is this? Pain & temp changes often precede skin color changes Discoloration may appear differently in darkly pigmented skin Injury results from intense / prolonged pressure and shear forces at bone-muscle interface
Deep Tissue PI
52
What stage is this? Wound may evolve rapidly to reveal actual extent of tissue injury or may resolve without tissue loss
Deep Tissue PI
53
Be careful not to use deep tisseue PI for ___, ____, ____, and ____.
Vascular, traumatic, neuropathic, or dermatologic conditions
54
What is the PI Assessment Tool we use?
PUSH Pressure Ulcer Scale for Healing
55
What are the 3 subscales of PUSH?
1. Surface Area 2. Exudate Amount 3. Wound appearance
56
What do the scores on PUSH mean?
* Can score 8-34, higher score = more severe wound * composite score can be used with multiple PIs * PUSH healing score calculated = Initial - Re-eval * (+) score reflects improvement
57
What stage can you put a dressing on?
Stage 1 or DTI for off loading positioning is key
58
Pressure-reducing device vs. Pressure-relieving device
Pressure-**reducing** device: reduces interface pressure more than standard hospital mattress/chair but not below 23-32 mm Hg Pressure-**relieving** device: consistently lower tissue interface pressure below the lowest measured capillary closing pressure of 23 mm Hg
59
Static support surface vs. Dynamic support surface
**Static** support surface: non moving device that provide cushioning & pressure distribution; can be used if pt doesn't "bottom out" **Dynamic** support surface: electric devices that use currents of air or fluid to redistribute pressure across the body
60
read through the pressure-reducing /relieving devices
slide 44-45 on PI lecture
61
What kind of exercise should you do with PI?
**ROM**: to prevent contracture **Strengthening**: for transfer & mobility **Aerobic**: for increased ability & improved Q **Gait training**: decrease risk for PI **Functional training**: maximize activity & mobility
62
Who is a Musculocutaneous Flap good for?
Stage 4 who have good prognosis to heal
63
How long does stage 1 PI take to heal?
1-3 weeks
64
How long does a Stage 2 PI take to heal?
days to weeks
65
How long does a Stage 3-4 PI take to heal?
8-13 weeks but can be up to 19 weeks

Integ (14 decks)

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