Pressure Injuries Flashcards
Where are pressure injuries generally located?
Over bony prominences
What are the characteristics of pressure wound tissue?
Varies from dark red to eschar
What are the characteristics of pain associated with pressure wounds?
Varies depending on structures involved
What are the characteristics of skin associated with pressure wounds?
Macerated, wet erythmatous
What are the characteristics of Exudate associated with pressure wounds?
Varies depending on location and presence of infection
What is the definition of Pressure ulcer?
Localized injury to skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combo with shear
How do you diagnose pressure wounds?
BY TISSUE INVOLVEMENT:
- Partial thickness
- Full thickness
- Underlying structures
BY CAUSE:
- Pressure
- Shear
- Friction
What are the stages of pressure wounds?
Stage I-IV
Unstageable
Suspected deep tissue injury
What are the characteristics of stage I pressure wounds?
Intact skin with non-blanchable redness of localized area, usually over bony prominence
Darkly pigmented skin may not have visible blanching; skin color may differ from surrounding area
Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
May be difficult to detect in individuals with dark skin tones
May indicate “at risk” persons
What are the characteristics of stage II pressure wounds?
Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough
May present as an intact or open/ruptured serum-filled blister
Presents as a shiny or dry shallow ulcer without slough or bruising
Stage II should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or denudement
What are the characteristics of stage III pressure wounds?
Full thickness tissue loss with visible subcutaneous fat (bone, tendon, or muscle are NOT exposed)
Slough may be present but does not obscure depth of tissue loss
May include tunneling or undermining
Depth varies by anatomical location. Areas with no subcutaneous fat may be shallow; areas with significant adiposity can be deep
Bone and tendons are not visible or directly palpable
What are the characteristics of stage IV pressure wounds?
Full thickness tissue loss with exposed bone, muscle, or tendon
Slough or eschar may be present on some parts of the wound bed
Often include undermining and tunneling
Depth varies by anatomical location (Areas with no subcutaneous fat may be shallow; areas with significant adiposity can be deep)
Exposed bone and tendons are visible or directly palpable
What are the characteristics of unstageable pressure wounds?
Full thickness tissue loss in which base of ulcer is covered with slough (yellow, tan, green, or brown) or eschar (tan, brown, black)
Until enough slough and eschar is removed to expose the base of the wound, the true depth, and therefore, stage cannot be determined
Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as a biological cover and should not be removed
What are the characteristics of a deep tissue injury associated with pressure wounds?
Area of discolored intact skin or a blood-filled blister due to damage to underlying tissue
Purple or maroon localized area of discolored intact skin or blood-filled blister from damage of underlying soft tissue from pressure and/or shear
Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue
May be difficult to detect in darker skin tones
Evolution may include a thin blister over a dark wound bed
Wound may further evolve and become a thin eschar
Evolution may be rapid, exposing additional tissue layers ever with optimal treatment
Pressure forces can cause what injuries?
Stage I
or
Deep tissue injury
What are the characteristics of pressure pathophysiology?
Increased interstitial fluid pressure
Decreased arteriolar circulation
Capillary collapse with thrombosis
Fluid loss through capillaries
Tissue edema
Autolysis of tissue
Decreased nutrients and oxygen to tissue
Inflammatory response-> ischemai-> necrosis-> ulceration
What are the characteristics of shear forces?
Parallel forces
Distort or break capillaries
Result in tissue anoxia
Cause wounds with undermining
Occur when patient sits up in bed or when sliding down in chair–skin is immobile on the support surface and the body moves
What are the characteristics of frictional forces?
Caused by two surfaces rubbing against each other
Abrade epidermis
Cause blisters with serous fluid
Decrease skin strength and integrity
Occur most commonly on foot or elbow
How does moisture affect the skin and wounds?
Decreases skin strength and thickness, thereby increasing risk of pressure ulcer
Macerates skin and increases the pH, decreases resistance to bacteria
Creates portals for bacteria to enter the skin
Causes diffuse, multiple partial-thickness ulcers, often with surrounding dermatitis
What are different types of moisture?
Urinary incontinence
Fecal incontinence
- Increases risk of bacterial infection
- Increase pH of the skin
Wound drainage
- May be caustic to the periwound skin, especially of from fistula
Perspiration
What is Incontinence Associated Dermatitis (IAD)?
Inflammation and skin erosion associated with exposure to urine, stool, use of absorptive contaminant device, secondary cutaneous infection (usually fungal) common
What is Intertrigo?
Inflammation in skin folds related to perspiration, friction and bacterial/fungal bioburden
What is Periwound maceration?
Skin breakdown from wound exudate, associated with volume of exudate, its constituents and bacterial bioburden
What are differential diagnostic criteria between IAD and Pressure Ulcer?
LOCATION:
- IAD is in skinfolds
- Pressure is on bony prominences
EDGE:
- IAD is diffuse and irregular
- Pressure has a distinct edge and is well circumscribed
COLOR:
- IAD is red/bright red, shiny
- Pressure is red/bluish
DEPTH:
- IAD is partial thickness
- Pressure is partial or full
NECROSIS:
- IAD has none
- Pressure is a yes/no
Successful treatment of pressure wounds depends on what?
Identify the cause
Discerning the movements and postures that result in the cause
Removing the cause
- Positioning to off-load
- Removing medical device causing damage
Modifying the movements and posture
Mobilizing the movements and posture
Mobilizing the patient
Standard wound care
How do you treat pressure ulcers?
Off-load or redistribute the pressure (do the hand check)
Debride necrotic tissue
Apply dressing that will maintain optimal moisture balance and protect the periwound skin from maceration
Treat infection or bacterial colonization with the appropriate antibiotics or antimicrobial dressings
Optimize patient nutrition for adequate protein and calorie requirements
Control blood glucose levels if patient has diabetes
Consider changes in meds that may be inhibiting wound healing
Educate patient, family, and caregiver about positioning to redistribute pressure
Use adjunct therapies for recalcitrant wounds
In terms of risk assessment, what are the characteristics of the Braden Scale?
Six subscales of risk, rate 1-4
Range 6-23 with lower score indicating higher risk
PREVENTION IS BASED ON LEVEL OF RISK:
- Mild risk = 15-18
- Moderate risk = 13-14
- High risk = 10-12
- Very high risk = < 9
