Pressure injuries Flashcards
What are never events
- events in a healthcare facility that should NEVER happen
- bloodstream infections
- UTI caused by catheters
- falls
- transfusion with wrong blood type
- surgery on wrong person or body part
- pressure ulcer while in the hospital
these must be reported
Lawsuits due to pressure injuries
- more than 17,000 lawsuits annually related to pressure ulcers
- it is the second most common claim after wrongful death
- average settlement is 250,00
- has led to criminal charges
Deathes related to pressure injures
- about 60,000 patients die as a direct result of a pressure ulcer each year
What is the Pathophysiology of pressure ulcers
- various risk factors that act over bony prominences and affect soft tissue
- when the pressure exceeds normal capillary pressure is when tissue damage is caused
- occulsion and tearing of small blood vessels
- reduced tissue perfusion
- ischemic necrosis
- pressure sore
What happens at the tissue level when a pressure injury occurs
- pressure occludes blood and lympathic circulation (in capillaries)
- increased interstitial fluid and increased venous pressure
- hypoxia and ischemia
- deformation of tissues
- when pressure relieved, sudden reperfusion damages (this can lead to chronic wounds)
what occurs at the capillary level with pressure injuries
- ischemia leads to hypoxic injury at cell
- lack of oxygen => insufficient ATP production => cell membrane pump fails
- cell membrane damage activated inflammation and DNA degradation and cell death
- damage at cell level with resultant edema and tissue damage exist prior to visible damage
damage occurs from inside out
Describe the time pressure curve for pressure ulcer formation
- low pressures = longer exposure time needed
- high pressure = shorter exposure time needed
more adipsoe tissue= pressure injuries may take longer
Name some supine pressure areas
- head
- shoulder
- elbow
- buttock
- heel
- toes: pressure of sheets and blankets
name some sidelying pressure areas
- ear
- shoulder
- elbow
- hip
- thigh
- leg
- both femoral condyles
- heel
Name some prone pressure points
- forehead
- cheeks
- nose
- chin
- clavicle/shoulder
- elbow
- chest/breast
- gentalia
- anterior pelvic bone
- knees/patella
- dorsal feet and toes
Name some seated pressure areas
- change amount of force through the surface depending on how reclined the back is
- head
- shoulder
- scapula
- sacrum
- buttock
- heel
- ball of foot
What is friction
- two surfaces move across one another
- dragging a pt across bed vs lifting a patient
- can cause pressure ulcers
What is shear
- a force applied parallel to soft tissue
- patient sliding down in bed, skin fixed, against sheets while skeleton slides downward
- creates tunneling/sinus
why would semi fowlers bed positioning be beneficial
- decreased sliding/shear
- HOB <30º decreased pressure
- caution with feeding tude as they need to be above 30ºto decrease risk of aspirating
Sidelying bed positioning
- 30º angle
- use pillows/wedges for support
- this is not functional
Intrinsic factors that can increase risk of pressure injuries
- nutrition
- age
- ciruculation
- underlying health status
Pressure injuries
extrinsic factors
- friction
- shearing
- moisture - incontinence/drainage/perspiration
- positioning/repositioning
Pressure injury characteristics
pain
- more proximal ulcers are likely to be painful
5 PT method
Pressure injury characteristics
position
- bony prominences
5 PT method
Pressure injury characteristics
presentation
- NPIAP ulcer classification system (staging)
5 PT method
Pressure injury characteristics
periwound
- non blanchable, indurated, mottled
5 PT method
Pressure injury characteristics
pulses
- pulse examination less routine (proximal before distal)
5 PT method
Pressure injury characteristics
temperture
- Hyperemia vs ischemia
5 PT method
How long does tissue desctruction take: 4 levels of skin breakdown
- hyperemia (blanchable redness) w/i 30 minutes or less (carefull this could become pressure ulcer)
- ischemia: in 2-6 hours of continuous pressure
- necrosis: occurs after 6 hours of pressure
- ulceration may occur in 2 weeks after necorsis
Stage 1 pressure ulcer characteristicsq
- intact skin
- non blanchable erythemia
- significant risk for future tissue destruction
- impaired integumentary integrity assoicated with superficial skin involvement
- signficiant risk for pressure injury/opening
stage 2 pressure ulcer characteristics
- partial thickness with loss of dermis
- shallow/open with red/pink wound bed
- no slough
- intact or ruptured serum filled blister (heel is most common)
- impaired integumentation integrity assoicated with partial thickness skin involvement and scare formation
Pressure ulcer stage 3 characteristics
- full thickness loss
- may see subcutaneous fat
- slough does not obscure wound bed
- impaired integumentary integriy assoicating with full thickness skin involvement and scare formation
- slough = at minimium stage 3
Stage 4 pressure ucler characteristics
- exposed or directly palpable bone, tendon, muscle
- often see underminin and or tunneling
- imapired integumentary integrity assoicated with skin involvement extending into fascia, muscle, bone and scar formation
unstageable pressure injury
- if base of wound is covered with slough or eschar
- dont know what stage b/c you dont know the depth
- stable eschar: dry, adherent, intact without erythema or fluctuanace; on an ischemic limb or the heels should NOT be removed
Suspected deep tissue injury (SDT) characteristics
- discolored, bruise, purple
- blood filled blist
- depth of tissue involvement is unknown
- these wounds are not open
What are the best practices for prevention of medical device related pressure ulcers
- choose the correct size of device
- cushion and protect skin with dressing in high risk areas
- remove: or move device daily to assess the skin
- avoid placement of device over sites or prior or existing pressure ulcers
- educate staff on correct use of device and prevention of skin breakdown
- be aware of edema under devices and potential for skin breakdown
- confirm that devices are no placed directly under and individual who is bedridden or immobile
Pressure ulcers in neonates and children: prevalence
- 27% PICUs
- 23% in NICUs
- 20-43% among patients with spina bifida
- most ulcers develop within 2 days of admission
Pressure ulcers in neonates and children: risk factors
- duration/amount of pressure/shear/moisture
- perfusion/malnutrition/infection/anemia
- immobility: spina bifida/CP/CABG surgeries
- medical devices: tubing/casts/splints
Terminal pressure ulcer/kennedy pressure ulcer
- occurs at the end of life
- terminal; may be position of comfort
- role = clean off and try to unload related to pain
- may not debride as much
- butterfly appearance on sacrum
not much to do
prevention of pressure injuries
- skin inspection and care
- nutritional management
- use of repositioning while avoiding friction or shear
- positioning and support surfaces for pressure relief
- increased mobility
- staff education and communication about patient status
What is the braden scale
- a risk assessment for pressure ulcers
- 6 subscales (mobility, activity, sensory, perception, skin moisture, nutrition, friction and shear)
- each subscale rated 1-4
- total score range 6-23
- < 13 = high risk; 13-14 = moderate risk; 15-18. = mild risk
What is the norton scale
- 5 subscales (physical condition, mental condition, activity, mobility, incontinence)
- scores range from 5-20
- 20 = no risk; < 16 = risk; < 13 = high risk
- acute care: on admission and 3 times per week
- SNF: on admission nad weekly
may be used anytime condition changes
Pressure ulcer scale for healing = PUSH tool
- developed by the national pressure injury advisory panel (NPIAP)
- A quick reliable tool to monitor the change in pressure ulcer status over time
pressure Wound intervention
- local wound care
- protect surrounding skin
- address wound bed: debridement, moisture balance
- minimze pressure and shear forces
- change position frequently
- educate patient and caregivers
Medical management of pressure injuries: risk factors
- malnutrition
- anemia
- diabetes
- incontinence
Medical management of pressure injuries: pharmacologic interventions
- antibiotics
- management co-morbidities
- monitor dementia and sedation
Medical management of pressure injuries: surgical interventions
- debridement
- skin grafts
- musculocutaneous flaps
Physical therapy interventions
for pressure injuries
- pressure reducing surfaces
- sit, supine, off loading
- therapeutic exercise
- flexibility, strength, aerobic, gait training
- functional training
- maximize patient activity and mobility
Support surfaces: reactive support surface
- a powered or nonpowered support surface with the capability to change its load distribution properties only in response to applied load
Support surfaces: active support surface
- a powered support surface with the capability to change its load distribution properties with or without applied load
Support surfaces: nonpowered
- any support surface not requiring or using external sources of energy for operation
Support surfaces: powered
- any support surface required or using exerternal sources of energy for operation
Support surfaces: Integrated bed system
- a bed frame and support surface that are combined into a single unit whereby the surface is unable to function separately
Support surface: mattress
- a support surface designed to be placed directly on the existing bed frame
overlay
- an additional support surface designed to be placed directly on top of an existing surface
