Module 8:Pt.2 Skin integrity and pressure injuries Flashcards
What are pressure injuries
Localized to the skin and underlying tissue, usually over bony prominences as a result of pressure, shear or friction.
What affects pressure injuries
Pressure shear friction moisture nutrition perfusion comorbidities
Why are older adults more likely to get pressure injuries
- Reduced elasticity of the skin, thinking
- polypharmacy (Taking multiple medications at once)
- medical conditions
- easily torn skin
- diminished inflammatory and immune system
- reduced hypodermic
- decreased nutritional intake
What is the pathogenesis of a pressure injury (3)
1) Intensity
2) Duration
3) Tissue tolerance
What is tissue ischemia
reduction of blood flow which can cause decreased sensation or tissue death
What is hyperemia
Redness, if it blanches it is bleaching hyperemia
What does it mean when a wound is non-blanching
possible dead tissue damage
but darkly pigmented skin doesn’t blanch
What extrinsic factors effect the tolerance of skin to pressure injuries
Shear, friction and moisture
What intrinsic factors effect the skins tolerance to pressure injuries
Poor nutrition, age, blood pressure
Risk factors for pressure injury development
1) Impaired sensory perception
2) Impaired mobility
3) Alteration in level of consciousness
4) Shear
5) Friction
6) Moisture
7) Nutriton
8) Tissue perfusion
9) Infection
10) pain
11) age
12) psychosocial impact of the wound
What is sheer?
Force exerted parallel to the skin and results on gravity pushing the body down.
happens when head of the bed is up to high or transfer onto a surface.
The subcutaneous layers adhere while the muscles and bones slider elsewhere causing necrosis
What is necrosis
Death of tissues
What kind of nutrition prevents skin wounds
High protein Prealbumin is the best biological indicator for malnutrition
- Calories for fuel and protection
- Protein for wound and immune function
- Vitamin C for collagen and capillary wall
- Vitamin A for wound closure and inflammation
- Zinc for collagen and cell membrane
- Fluid for cell environment
What is tissue perfusion
when the tissue needs oxygen can happen in shock or diabetes
What are signs that a wound is infected
Pain and tenderness Erethema( Redness) Edema Induration (firmness) Purulent discharge Warmth fever chills odour elevated WBC delayed healing
Assessment questions to ask
- Sensation (any loss or increased sensitivity)
- Mobility (Any limits?)
- Continence (any difficulty)
- presence of a wound (NOPQRSTUV)
Can you classify a wound if its covered with necrotic tissue?
No its dead tissue on top
You cannot tell how deep it is
Include % of nonviable tissue
and viable tissue
What are the characteristics of a suspected deep tissue injury
Skin: Intact or non intact
- nonblachable deep red purple discolouration
- separation revealing dark would bed or blood filled blister
- result from intense or prolonged pressure and shear focus
- may evolve rapidly or resolve without an issue
What are the characteristics of a stage 1 Pressure injury
- Intact skin
- Nonblanchable erythema
- changes in sensation, colour, temp or firmness
- NOT MAROON OR PURPLE
Characteristics of stage 2 pressure injury
- Exposed dermis
- pink or red wound bed
- moist or a blister
- fat not visable
- no granulation tissue, slough or eschar
Characteristics of stage 3 Pressure injury
- Fat in skin is visible deep below
- Granulation tissue and epibole (rounded edges) are present
- slough and eschar might be present
- No tendon, muscle or bone exposed
Characteristics of stage 4 pressure injury
- Full thickness of skin an tissue loss with exposed and palpable tendon muscle ligament and bone
- Slough and eschar probably visible
- epibole, undermining and tunneling
Characteristics of an unstagable pressure injury
Extend of tissue loss cannot be confirmed because it is obstructed by slough or eschar
- Stable eschar should sometimes not be removed
- a stage 3 or 4 pressure injury will be underneath
what is slough
dead skin tissues
-stringy substance attached to wound bed that needs to be detached before it can heal
What is eschar
dry dark scab, usually needs to be removed
What is granulation tissue
Red, moist with new blood vessels
-Shows progression towards healing
What is exudate
Amount colour and consistency/ odour or wound drainage, excessive can mean infection
What is a wound
Disruption in the integrity and function of a tissue in the body
What is primary intention
A low risk surgical wound
What is secondary intention
A burn, pressure ulcer, laceration that is left open until it fills with scar tissue
What is an acute wound
- Proceeds through orderly and timely reparative process
- From trauma, surgery, or incision
- easily cleaned with intact edges
What is a chronic wound
- fails to proceed orderly and timely process to produce anatomical and functional integrity
- vascular compromise chronic inflammation, reparative insults to tissue
- continued exposure to insult impedes healing
What is tertiary intention
- contaminated or inflammed
- healing is delayed until risk of infection is resolved
Safe client handling for health care workers
- arrange for help
- heigh adjustable beds to tallest person
- air assisted devices
- friction reducing sheets
- encourage patient to help
- take position close to patient
- avoid twisting
- bend at knees
- slide patient towards using pull sheets
- heaviest load coordinates the effort
What is a foot boot
keeps foot flexed and weight of bedsheet off toes
what is a trochanter roll
prevents external rotation of hips in supine position
What do sandbags do
help with alignment
what do hand rolls do
maintain thumb opposition
What does the trapeze bar do
Triangular device decides from a securely fastened overhead bar attached to the bed frame can use arms to raise off of the bed
What is supported fowlers position
- A bed sitting position basically
- head of bed up, knees slightly elevated
- Can cause cervical flexion if neck pillow is too big
- hyper extension of knees if feet slide to end of bed
- pressure on posterior aspect of knees
- decreased circulation to feet
- external rotation of hips
- arms hanging unsupported at sides
- pressure on heals
- **unprotected pressure points on sacrum and heels
- sheering force on back and heels
- DONT PUT THE BED MORE THAN 60 DEGREEESSS
Supine Postion
- Back lying position
- sounderes supported, elbows slightly flexed
- foot support used
- cervical flexion if pillow is too big
- shoulders not supported
- hips can rotate out
- **pressure points at occipital region, vertebrae, coccyx, elbow and heels
Prone Postion
- Chest down
- some respiratory benefit
- **unprotected pressure pt @ Chin, elbows, hips, knees and toes
Lateral position
- Lateral flexion of the neck
- spinal curve our of normal allignment
- shoulder and hip joints internally rotated and unsupported
- lack of feet support
- **lack of protection on ear, shoulder, anterior iliac spine, trochanter and ankles
Sims position
- How I like to sleep lol
- weight placed on anterior ilium, humorous and clavical
- lateral flexion of the neck
- internal rotation, abduction or lack of support to shoulders and hips
- **Pressure pt. on ilium, humorous, clavicle, knees and ankles
What is the first priority when repositioning patients
A safe transfer
Functional assessment to do before you move someone
- They can communicate their needs
- they can comprehend and follow instructions
- hearing, vision
- medical status (things that limit mobility)
- attachment to appliances
- pain and fatigue
- asses hand grip strength
- can they bridge
- can they roll side to side
- sitting position of side of bed
- straighten and hold legs for 3 seconds
- can they get into a standing position
- can they bear body weight for 15 seconds
- are the predictable?
- Need 2 nurses if deficient in any of these areas
When should you start ROM exercises?
As soon as the pt can move the joint
