Pressure Injuries Flashcards
define a pressure injury
local damage to skin and underlying tissue (usually over a bony prominence or related to a medical or other device). Skin can be intact or open and may be painful
under what conditions will CMS decline hospital reimbursement for pressure injury care
if the injury was not present on admission (within 48 hours of admission) and has progressed to stage 3 or 4.
what are the four factors that influence the etiology of pressure wounds
pressure, friction, shear, and moisture
define pressure
force is applied perpendicular to bony prominence or device
where does pressure exert the most damage
in areas with little subcue tissue
how does a pressure wound develop
deep to superficial according to the following steps 1. increased interstitial fluid pressure 2. decreased arteriole circulation 3. capillary collapse leading to fluid leakage 4. edema 5. tissue autolysis 6. decreased nutrients and oxygen to tissues
what are the four phases culminating in pressure ulcer development
inflammatory response > ischemia > necrosis > ulceration
with regards to pressure ulcer development, whats the difference between blanchable and nonblanchable erythema
blanchable - damage is reversible with about 24 hours of pressure relief non blanchable - first sign of pressure injury formation
define friction as it relates to ulcerations
epidermis is rubbed, pulled across, or abraded from the deeper layers parallel to the force
define shear
a combination of force and friction
how does moisture impact wound development on healthy integument?
prolonged moisture exposure can cause maceration making the skin less resistant to mechanical stress
where are the common sites of pressure injuries in sitting
heels, IT, sacrum, elbows, spinous processes, scapulae
what are the characteristics of stage 1 pressure injuires
- skin intact (can run your hand across and not feel a difference)
- non-blanching redness or darker pigmented skin
- sensory changes
- purple or maroon may indicate a deep tissue pressure injury
what are the characteristics of a stage 2 pressure injury
- partial thickness with exposed dermis
- viable, pink/red, moist, or serum filled blister
what is MASD and how do you classify it
moisture associated skin damage - cannot stage classify
what is IAD and how do you classify it
incontinenece associated dermatitis - cannot stage classify it
what is MARSI and how do you classify it
medical adhesive related skin injury - cannot stage classify it
what are the characteristics of a stage 3 pressure injury
- full thickness loss of skin
- rolled edges
- fat, granulation tissue, slough, and eschar all may be visible
what makes a pressure injury unstageable
slough or eschar obscuring the extent or depth of tissue loss - once removed, the wound will be either stage 3 or 4 exclusively
what are the characteristics of a stage 4 pressure injury
- full thickness
- palpable fascia, bone, tendon, ligament, or muscle
- slough or eschar may be present
what condition is associated with bone exposure due to pressure injury
osteomyelitis
at which of the 4 pressure injury stages may we see epibole, undermining, or tunneling
stage 4
where are we most likley to see pressure injuries in proned patients
knees, ASIS, clavicle, facial bones
a patient has had a R TKA, which heel (R or L) are we most likely to see the development of a PI
the operative leg (R)
what are the six domains of the Braden Scale for pressure injuries
how is the Braden Scale generally interpreted
- sensory
- moisture
- activity
- mobility
- nutrition
- friction/shear
the lower the overall score, the higher likelihood of pressure injury
what are the three domains of the PUSH Tool and what is its major drawback according to Michelle
- LxW
- Exudate amount
- tissue type
it doesn’t account for depth or undermining
what are the five pressure injury prevention concepts for bed-bound individuals
- reposition q2hrs with a 30 deg turn
- use pillows and wedges to keep the bones off the bed
- minimize HOB elevation to prevent shear
- lift instead of slide to move the patient
- check equipment frequently
how would you use a doughnut in the acute setting to manage pressure injuries
trick question, do not use doughnuts because they can increase ischemia, venous congestion, and/or edema
what is a group 1 support surface
overlays and reactive therapeutic mattress replacements
what is a group 2 support surface
active powered mattress replacements
what is a group 3 support surface
air-fluidized beds
what is the difference between a reactive therapeutic mattress and a active powered mattress
RTM (group 1) only reacts to the patient when the patient is in the bed and a APM (group 2) can react without patient contact
what are the 3 pressure injury prevention concepts for chair-bound individuals
- q15-30min for at least 1 min
- use pressure reducing devices
- consider wheelchair Rx (tilt in space)
