Pressure Injuries Flashcards
Pressure Injury
Definition
Preventable localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of unrelieved pressure with/out shear or friction.
Pressure Injury
Pathophysiology
Prolonged exposure to pressure exceeding arterial capillary pressure (32mmHg) and venous capillary closing pressure (8-12mmHg) > impaired blood flow to/from area > tissue ischemia > inflammatory response > increased capillary permeability > accumulation of waste products and protein leakage into EVS > progressive necrosis of tissue extending outward/downward.
+/- friction - erosion of superficial skin layers.
+/- moisture - decreased tensile strength of skin.
Pressure Injury
Visual Progression
Blanching erythema +/- changes in sensation, temperature or firmness > non-blanching erythema > blister-formation > open wound > cavity wound.
Braden Scale
Criteria
- Sensory perception – ability to respond meaningfully to pressure-related discomfort (complete, very, slight or nil limitation)
- Moisture – degree to which skin is exposed to moisture (constant, very, occasionally or rarely)
- Activity – level of physical activity (bedfast, chair-fast, occasional or frequent walking)
- Mobility – ability to change and control body position (complete, very, slight or nil limitations)
- Nutrition – usual food intake pattern (poor, likely inadequate, adequate, excellent)
- Friction/sheer – degree of skin sliding against sheets, chair, restraints or other devices during movement (actual, potential or nil problem)
Intrinsic Risk Factors (4)
- Older age - loss of subcutaneous tissue, collagen and elasticity; decreased immune function; decreased circulation; impaired sensation.
- Immobility/inactivity - decreased circulation; failure to offload; assisted transfers/repositioning.
- Malnourishment - impaired immune function and healing; decreased skin cell production/support.
- Co-morbidities - anaemia, DTM, PVD/PAD, neuropathy, arthritis.
- Pressure points/bony prominences - occiput, sacrum, heels, hops, scapula, elbows.
Extrinsic Risk Factors (6)
- Pressure - continuous physical force exerted on/against skin (>32mmHg = arterial closing pressure)
- Shear - parallel/tangential force sliding/dragging skin (exacerbates pressure).
- Friction - opposite pushing/pulling forces created by rubbing surfaces.
- Moisture - reduces tensile strength of skin (softens stratum corneum)
- Temperature - inflammatory response to skin cell erosion OR decreased temperature and impaired circulation.
- Time - inverse effects of pressure and time (30min = min time for irreversible damage)
Pressure Injury - Stage 1
Localised non-blanching erythema of intact skin.
NOT purple/maroon.
Pressure Injury - Stage 2
Partial thickness tissue loss (epidermis only) with exposed dermis.
Viable, pink/red, moist tissue or serum-filled blister.
Pressure Injury - Stage 3
Full thickness tissue loss with exposed adipose tissue.
MAY involve granulation tissue, rolled edges, slough/eschar, undermining/tunnelling.
Pressure Injury - Stage 4
Full thickness tissue loss with exposed muscle, tendon or bone.
Pressure Injury - Unstageable
Full-thickness tissue loss in which depth is unknown as wound bed obscured by devitalised tissue (slough, eschar, necrotic tissue). Debridement required to ascertain depth.
Pressure Injury - Suspected Deep Tissue
Damage of underlying soft tissue manifesting as localised purple/maroon discolouration of intact skin OR blood-filled blister. Preceded by painful, firm or mushy/boggy, temperature changes.
Negative Pressure Wound Therapy
Definition
Indications
Pressure Injury
Management (9)
- Repositioning (2/24)
- Rule of 30
- Offloading devices
- Protective dressings
- Support surfaces
- Skin care
- Incontinence care
- Nutrition and hydration
- Patient education
Out-dated Methods (4)
- Massage
- IV bags or water-filled gloves
- Ring cushions
- Sheepskins
