Personal care and pressure injuries

Question 1

What is involved in personal care

Answer 1

-pressure injury prevention
-menstrual care
-stoma care
-eye care
-mouth care
-toileting/ continence care
-washing
-dressing (clothing)
-food and hydration

Question 2

Pressure injury definition-

Answer 2

Pressure injuries are defined as localized damage to the skin as well
as underlying soft tissue, usually occurring over a bony prominence or
related to medical devices. They are the result of prolonged or severe
pressure with contributions from shear and friction forces

Question 3

Areas at greater risk of pressure injuries

Answer 3

-back of head
-scapula
-vertebrae
-sacrum
-buttocks
-heels
-hips

Question 4

Pathophysiology of pressure injuries

Answer 4

1.pressure- constant pressure applied to specific area of the body which disrupts blood flow to the area
2.ischemia (tissue death)- prolonged pressure compresses blood vessels limiting oxygen and nutrients to the tissue causing cell and tissue death
3.tissue hypoxia- tissues start to die resulting in necrosis
4.inflammatory response- aims to clear damaged tissue but in pressure injuries, the inflammatory response is prolonged and can exacerbate tissue damage
5.tissue breakdown- damaged tissues breakdown resulting in pressure injury

Question 5

Shear
what is it, example

Answer 5

-when different layers of tissue move in opposite directions
-eg. a patient shuffling up a bed, the “body” moves up
the bed, but the skin is pulled down

Question 6

Friction
what is it, what it does, example

Answer 6

-resistance encountered when the skin is dragged across a surface.
-these forces can weaken the skin’s integrity, making it more susceptible to injury.
-eg. dragging a patient up the bed.

Question 7

Category 1 pressure injury

Answer 7

-localised area of non blanchable erythema of intact skin
-just looks like a red patch on skin

Question 8

Category 2

Answer 8

-partial skin loss with exposed dermis
-wound bed has blood supply
-is pink/red
-can be moist, shiny or dry

Question 9

Category 3

Answer 9

-full thickness skin loss
-adipose/ fat tissue is visible (yellow blobs)

Question 10

Category 4

Answer 10

-full thickness skin and tissue loss
-exposed muscle, tendon cartilage, ligament or bone

Question 11

Unstageable pressure injury

Answer 11

-obscured full thickness skin/ tissue loss
-extent of tissue damage can’t be determined
-closed skin

Question 12

Deep tissue pressure injury

Answer 12

-persistent non blanchable deep red/ purple discolouration
-skin can be intact or not

Question 13

If patient can’t reposition independently

Answer 13

-position in 30 degree lateral tilt supported by pillows or blankets
-position head of stretcher no more than 30 degrees, shouldn’t be full sat up
-off load heels from surface of bed using pillows or blankets

Question 14

Preventing pressure damage
5 steps

Answer 14

SSKIN
-surface- ensure it offers sufficient pressure relief
-skin inspection- early inspection enables early detection making easier to treat
-keep patient moving
-incontinence/ moisture- keep patient clean and dry
-nutrition/ hydration- right diet and plenty of fluids keeps patients skin healthy