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Integ > Lecture 4b - Pressure Injuries > Flashcards

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
Q

What do the scores on a Norton Risk Assessment Scale mean?

A

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

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26
Q

What are the 5 subscales of the Gosnell Pressure Score Risk Assessment?

A
  1. Mental Status
  2. Continence
    3. Mobility
    4. Activity
  3. Nutrition
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27
Q

What do the scores on the Gosnell Pressure Score Risk Assessment mean?

A

Can score 5-20, higher = greater risk
* 16 = critical cut off

not enough research here

28
Q

Should you use donut-type devices to assist with positioning?

A

No, they increase tissue congestion, vascular occlusion, and pressure

29
Q

Who needs to assist patients who are unable to reposition themselves?

A

Caregivers and healthcare workers

30
Q

For every gram decrease in serum ALB below normal, the risk of PI increases _____fold

serum ALB = albumin

A

Fourfold

31
Q

What can you use to help with incontinence to prevent PI?

A

Moisture barriers, frequent checks for wetness and speedy (gentle) clean up

32
Q

T/F: With PI Staging, patients can downgrade and upgrade

A

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
Q

What stage is this?

non-blanchable erythema of intact skin

A

PI Stage 1

34
Q

What stage is this?

Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes

A

PI Stage 1

35
Q

What color changes may indicate deep tissue pressure injury?

A

Purple or maroon discoloration

36
Q

What stage is this?

Partial-thickness skin loss with exposed dermis

A

PI Stage 2

37
Q

What stage is this?

Wound bed is viable, pink or red, moist, may also present as intact or ruptured serum-filled blister

A

PI Stage 2

38
Q

What stage is this?

Adipose is NOT visible & deeper tissues are NOT visible. granulation tissue, slough, and eschar are NOT present

A

PI Stage 2

39
Q

What stage is this?

Commonly results from adverse microclimate and shear in skin over pelvis and shear in the heel

A

PI Stage 2

40
Q

What is PI stage 2 NOT?

A

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
Q

What stage is this?

Full-thickness skin loss

A

PI Stage 3

42
Q

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

A

PI Stage 3

43
Q

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

A

PI Stage 3

44
Q

If slough or eschar obscures the extent of tissue loss, this is ______ _______ ______

A

Unstageable Pressure Injury

45
Q

What stage is this?

Full thickness skin and tissue loss

A

PI Stage 4

46
Q

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

A

PI Stage 4

47
Q

What stage is this?

Slough and/or eschar are visible

Epibole, undermining and/or tunneling OFTEN occur

Depth vaires by anatomical position

A

PI Stage 4

48
Q

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

A

Unstageable PI

49
Q

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

A

Unstageable PI

50
Q

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

A

Deep Tissue PI

51
Q

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

A

Deep Tissue PI

52
Q

What stage is this?

Wound may evolve rapidly to reveal actual extent of tissue injury or may resolve without tissue loss

A

Deep Tissue PI

53
Q

Be careful not to use deep tisseue PI for ___, ____, ____, and ____.

A

Vascular, traumatic, neuropathic, or dermatologic conditions

54
Q

What is the PI Assessment Tool we use?

A

PUSH

Pressure Ulcer Scale for Healing

55
Q

What are the 3 subscales of PUSH?

A
  1. Surface Area
  2. Exudate Amount
  3. Wound appearance
56
Q

What do the scores on PUSH mean?

A
  • 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
Q

What stage can you put a dressing on?

A

Stage 1 or DTI for off loading

positioning is key

58
Q

Pressure-reducing device vs. Pressure-relieving device

A

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
Q

Static support surface vs. Dynamic support surface

A

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
Q

read through the pressure-reducing /relieving devices

A

slide 44-45 on PI lecture

61
Q

What kind of exercise should you do with PI?

A

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
Q

Who is a Musculocutaneous Flap good for?

A

Stage 4 who have good prognosis to heal

63
Q

How long does stage 1 PI take to heal?

A

1-3 weeks

64
Q

How long does a Stage 2 PI take to heal?

A

days to weeks

65
Q

How long does a Stage 3-4 PI take to heal?

A

8-13 weeks but can be up to 19 weeks

Integ (14 decks)

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