Pressure Injuries Flashcards by Sydney Perry

Pressure Injuries
- pressure ulcer, decubitus ulcer, bed sore

Localized damage to the skin and/or underlying tissue usually over a ____ prominence, as a result of pressure or pressure in combination with _________

bony
shear and/or friction

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The tolerance of soft tissue for pressure and shear may also be affected by the ________, _________, _________, and ________.

microclimate
nutrition
perfusion comorbidities
condition of the soft tissue

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Pressure injuries are among the most common conditions encountered in patients ___________ or requiring __________ care

Estimated 2.5 million pressure injury cases/year in the U.S

acutely hospitalized
long-term institutional

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Ischemic ulcers/injuries

unrelieved pressure occludes __________ resulting in an inadequate supply of __________ to the ________ and __________

capillary blood flow
oxygen & nutrients
epithelium
supportive tissue

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Common sites => _________________________

sacrum, heels, hips, greater trochanters, ankles, elbow, shoulder, back of the head, inner knees

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Primary Risk factors for pressure injuries

unrelieved pressure over bony prominences
friction and shearing forces
moisture
immobility

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Secondary risk factors for pressure injuries

malnutrition
body weight
fever
infection
anemia
vascular changes
neurological changes
decreased sensation
incontinence
iatrogenic factors

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Shear is a ___________ that causes a __________ to move across the _____ as the _____ is held in place

Internal body structures and skin tissues moving in opposite directions leading to:
___________ and __________

horizontal force
bony prominence
tissue
skin

Friction between the skin and surface
Shear strain deep within the tissue

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Guidelines provided by the _____________ for stages

National Pressure Injury Advisory Panel (NPIAP)

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Stages of Pressure injuries

Stage 1
Stage 2
Stage 3
Stage 4
Unstageable Pressure Injury
Deep Tissue Pressure Injury

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Tissue layers from surface inward

Epidermis
Dermis
Adipose Tissue
Muscle
Bone

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Stage 1 Pressure Injury

_____ skin with __________ of a localized area

May be difficult to detect in those with _______

Area may be _____ and ______ compared to adjacent tissue

Intact
non-blanchable redness

darker skin tones

painful
warm

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Stage 2 Pressure Injury

________ with ________

Presents as a _________ ulcer with a _______ and ________

The wound bed is ______, ______, and may also present as

Partial-thickness skin loss
exposed dermis

shallow, open
red-pink wound bed
without slough

viable
moist
an intact or ruptured serum-filled blister

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Stage 3 Pressure Injury

_________ skin loss involving __________

________ may be visible but __________ are not exposed

Presents as a ______
_________ may be visible

Full-thickness
damage to or necrosis of subcutaneous tissue

Subcutaneous fat
bone, tendon, & muscle

deep crater
Slough and/or eschar

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Stage 4 Pressure Injury

_________ skin loss with exposed ____________(4)

_____ or _____ may be present

______, ______, and ______ often occur

Can extend into _____, _____, and ______

Can result in _________

Full thickness
muscle, tendon, ligaments, or bone

Slough or eschar

Epibole, undermining, and tunneling

muscle, tendons, & joint capsule

osteomyelitis

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Unstageable Pressure Injury

_____________ loss in which the actual depth of the ulcer and extent of tissue damage is ______________ in wound bed

The true depth, and therefore stage, cannot be determined until the ____________ but will then be either a ________

full-thickness skin and tissue
obscured by slough &/or eschar

slough &/or eschar are removed
Stage 3 or 4

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Deep Tissue Pressure Injury

Persistent _________ injury with ___________ discoloration due to intense &/or prolonged pressure and shear forces at the bone-muscle interface

non-blanchable deep
red, maroon, or purple

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Complications from Pressure Injuries

Pain
Infection: ______, _______, _______, and _______

Associated with _________, ___________, __________, and ______

abscess
cellulitis
bacteremia
osteomyelitis

decreased QOL
prolonged hospital stay
increased health care costs
increased mortality

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All patients should be screened on admission to any health care agency and periodically reassessed using the

“________________”:

Examines: sensory perception, moisture, activity, mobility, nutrition status, friction/shear
Score of < 12 indicates high risk for developing pressure injuries
For those determined to be at risk=> Daily skin assessment

Braden Scale for Predicting Pressure Sore Risk

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The Braden Scale for Predicting Pressure Sore Risk examines __________, ________, _______, ______, _________, ________

score of ____ indicated high risk for developing pressure injuries
for those at high risk, they should get ____________

sensory perception, moisture, activity, mobility, nutrition status, friction/shear

≤12

daily skin assessment

Relieve or redistribute pressure:

Bed-bound persons: Turn & reposition at least once every ______

Chair-bound persons: Reposition every ______

Persons who are able should shift weight every ________

2 hours
hour
15 minutes

other than moving the patient, ______, ____________ and ___________ can help

Pressure-relieving mattresses

Pillows & foam wedges under or between bony prominences

Increase activity/movement (e.g., wheelchair push-ups)

Avoid friction & shearing by using
________ and Maintain _________ (if appropriate with medical condition) for those on bed rest

Lifting devices
HOB <30-degree angle

Skin care:
Keep skin clean
Avoid _______
_________ for incontinence
Adequate _______
Maintain/replete nutritional stores

excessive moisture
Bowel & bladder programs
hydration

treatment and management - Interdisciplinary approach - Improve tissue perfusion by eliminating pressure - Wound ___________ - Debridement of _________ - Monitoring for and treatment of _______ - Operative repair: ____________and________ - MNT

cleansing & dressing necrotic tissue infections debridement, skin grafts

Evaluation of healing or lack of healing: _____________ Tool (Pressure Ulcer Scale for Healing) can be used for evaluation of healing

National Pressure Injury Advisory Panel’s PUSH

Factors that Interfere with Wound Healing Malnutrition Infection Ischemia Smoking Diseases/conditions: __________ Medications: __________

atherosclerosis, CHF, ischemia obesity, immunologic deficiencies, diabetes/hyperglycemia immunosuppressant drugs corticosteroids

Appetite Current weight & weight history: underweight, obese, ________ Adequacy of total nutrient intake: _______ Current medical status and PMHx Medications Functional status: __________ Chewing/swallowing GI status

unintentional weight loss current & PTA Ability to eat independently

Nutrition-Focused Physical Examination: _______ ________ ________ which involves ______, ______, and ______

Muscle wasting Vitamin or mineral deficiencies Wound Analysis - Number of pressure injuries - Staging & size - Drainage (fluid & protein losses)

Laboratory Assessment ____________=> hydration status ________=>________ can delay wound healing

Serum Na, BUN, Osm Glucose hyperglycemia

Wound healing requires energy for _____, _____, and _______ Underfeeding impairs wound healing ENERGY: Provide ________ with a pressure injury who are malnourished or at risk for malnutrition Individualize based on medical conditions and level of activity May need to adjust kcal to promote weight gain or loss

synthesis of collagen cell metabolism angiogenesis 30-35 kcal/kg

Sufficient protein needed for ________, _________, and ________ Protein can be lost in __________ and __________ Protein deficiency delays wound healing Goal is to provide adequate protein for positive nitrogen balance

cell synthesis collagen & connective tissue formation immune function wound exudate & drainage

PROTEIN: Provide __________ for adults with a pressure injury who are malnourished or at risk of malnutrition Patients should consume ________ of high-quality protein at each meal to increase protein synthesis

1.25-1.5 g protein/kg 25-30 g

_______ is a conditionally essential amino acid during periods of acute metabolic stress and injury

arginine

Arginine promotes the transport of ________ into tissue cells Can enhance wound ______ and ________ Stimulates the release of ________ and ___________ which can improve wound healing

amino acids strength collagen deposition growth hormone insulin-like growth factor 1

Arginine may promote wound _______, improve __________, enhance _________ Clear and definitive guidelines for its safe & effective use?

repair nitrogen balance immune function have yet to be established

Adequate fluid intake is needed for good ________ and _______ of healthy tissue and wounds Monitor for signs of dehydration Commonly used formula: _______ or _______

perfusion oxygenation ~30 ml/kg or 1 ml fluid/kcal

Provide additional fluid for those with:

Heavily draining wounds Fever Dehydration Vomiting or diarrhea High protein intake may require additional fluids

Deficiencies in _____, _____ and ______ can inhibit wound healing

vitamin C zinc copper

Encourage a balanced diet to include good sources of vitamins & minerals Provide/encourage vitamin & mineral supplementation only when _______________

dietary intake is poor or deficiencies are confirmed or suspected

vitamin C Aids in ________ Also required for ___________ formation and stimulation of ________ activity Vitamin C deficiency has been associated with delayed wound healing, increased risk of wound infection and dehiscence

collagen synthesis capillary & fibroblast neutrophil

Is vitamin C stored in body? At risk=> individuals with _________ the ______, ________ individuals, _______, individuals who eat no _______

no alcohol use disorder elderly severely injured smokers fruits or vegetables

In non-deficient individuals, vitamin C ___________ If deficient: Recommend ______ for ______ If renal failure, avoid supplementation of _______ due to the risk of renal ______ formation

has not been proven to enhance wound healing 100 mg TID 1 month >200 mg/d oxalate stone

ZINC Required for: ______________ synthesis _________ synthesis ___________________

Protein & DNA Collagen Cell replication & growth

Zinc deficiency can result in _________ and ____________ Individuals at risk for deficiency=> ______, ______, _____, and ______

delayed wound healing impaired immune function diarrhea malabsorption metabolic stress elderly

Lack of studies showing significant benefit of Zn supplementation on pressure injury healing in the absence of _______ For deficiency, the optimal supplemental dose is ________ If clinical signs of Zn deficiency are present provide: ________ for _______ Doses ________ may inhibit ________ by interfering with _______ Often provided as ______ of which _____ is elemental zinc

Zn deficiency unknown 25-40 mg/d of elemental Zn daily for 10 days >50 mg/d wound healing copper absorption zinc sulfate 23%

MNT FOR PRESSURE INJURIES Provide high _____ and high ________ foods or _____________________ If needed and consistent with patient wishes, use of ___________ with _____________ formulas

kcal protein fortified oral nutrition supplements between meals supplemental tube feedings high protein, nutritionally complete

Recommendation from the International Guideline on the Prevention and Treatment of Pressure Ulcers/Injuries: Provide high-calorie, high-protein, ________, _____ and ________ ONS (oral nutrition supplement) or _______ for adults with a ______ or greater pressure injury who are malnourished or at risk of malnutrition.

high-calorie arginine zinc enteral formula Stage 2