Pressure and friction injuries Flashcards
What is a pressure injury?
a wound caused by unrelieved pressure against the skin usually over a boney prominence, resulting in localized ischemia and/or necrosis of the underlying tissues
Describe a stage I pressure injury
- Intact skin with non-blanchable redness of a localized area
- Usually over a bony prominence
Describe a stage II pressure injury
- Partial thickness loss of dermis presenting as a shallow ulcer with a red-pink wound bed, without slough
- May also present as intact or open/ruptured serum-filled blister
Describe a stage III pressure injury
- Full thickness tissue loss
- Subcutaneous fat visible but bone, tendon, or muscle is not
- Slough may be present but does not obscure the depth of tissue loss
- May include undermining or tunneling
Describe a stage IV pressure injury
- Full thickness tissue loss with bone, tendon, or muscle exposure
- Slough or eschar may be present on some parts of the wound bed
- Often includes undermining and tunneling
Describe an unstageable pressure injury
Full thickness tissue loss in which base of ulcer is covered by slough and/or eschar in the wound bed
How much pressure is exerted on the ischial tuberosities while sitting and supine?
- Sitting - 300 mm Hg
- Supine - 70 mm Hg
What level of pressure can cause damage if not relieved?
> 32 mm Hg
What else can compound with pressure damage?
- Shearing - skin and subcutaneous tissue displaced in opposite directions, tearing small vessels, and limiting perfusion
- Moisture - macerated skin begins to erode
- Heat - As heat increases -> compressed capillaries can’t dissipate -> metabolism increases -> cell death is accelerated
- Friction - single sided force on the skin causing blisters or abrasions
How does a friction injury differ from a pressure injury?
- More shallow
- Do not become chronic
- Varies in shape and may be very large
- wound edges - scaling and ridging
What score on the Norton scale indicates a patient is at risk for pressure injury?
14 or less
