pressure injury Flashcards
pressure injuries/ulcers
-caused by pressure applied to susceptible tissues
-tissue susceptibility increased in presence of maceration and by friction / shear forces.
-Chronic conditions, especially immobility and decreased tissue perfusion
-develop over bony prominences -> MC sacrum, heels, and trochanteric areas.
-develop in acute hospitals -> MC orthopedic and ICU pts.
-Tx options differ depending on type and stage of wound and are often difficult to heal
-high impact on the quality of life of a pt as well as caregivers.
-Significant cost to health care and increased mortality rates in acute and long-term care
-INTENSE FULL CAREFUL SKIN EXAM PRIOR TO ADMISSION- document !
-high protein diet -> healing
risk factors
-Presence of a fracture
-Hx of previous pressure ulcer
-Recent institutional discharge
-Age
-Incontinence
-Immobility
-Functional impairment
-Decreased serum albumin level
-Lymphopenia
-Non-blanchable erythema
-Dry skin
-Decreased wt
-Nutritional status
category/stage 1: non blanchable erythema
-Intact skin with non-blanchable redness of a localized area usually over a bonyprominence
-Darkly pigmented skin may not have visible blanching, colormay differ from the surrounding area
-painful, firm, soft, warmeror cooler as compared to adjacent tissue
-may be difficult to detect inindividuals with dark skin tones
-May indicate “at risk” persons.
category/stage 2: partial thickness
-Partial thickness loss of dermis
-shallow open ulcer with red/pink wound bed, without slough
-can also be intact or open/rupturedserum-filled or sero-sanginous filled blister.
-shiny or dry shallowulcer without slough or bruising
-Bruising indicates deep tissue injury.
-This category should not be used to describeskin tears, tape burns, incontinence associated dermatitis, maceration orexcoriation
category/stage 3: full thickness skin loss
-Full thickness tissue loss
-Subcutaneous fat may be visible but bone, tendon ormuscle arenot
-Slough may be present but does not obscure the depthof tissue loss.
-bridge of nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue ->Category/Stage III ulcers can be shallow.
-In contrast, areas of significantadiposity can develop extremely deep Category/Stage III pressure ulcers
-Bone/tendon is not visible or directly palpable
category/stage 4: full thickness tissue loss
-Full thickness tissue loss with exposed bone, tendon or muscle.
-Slough or escharmay be present
-Often includes undermining and tunneling.
-Ulcers can extend intomuscle and/or supporting structures (e.g., fascia, tendon or joint capsule) makingosteomyelitis or osteitis likely to occur
-Exposed bone/muscle is visible or directlypalpable
unstageable/unclassified: full thickness skin or tissue loss: depth unknown
-Full thickness tissue loss in which actual depth of the ulcer is completelyobscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brownor black) in wound bed
-Until enough slough and/or eschar are removed -> true depth cannot be determined;
-Stable (dry, adherent, intact without erythema orfluctuance) eschar on the heels serves as “the body’s natural (biological) cover”and should not be removed
-slough and eschar is on top of the ulcer -> cant see how deep it is -> take it off and then stage
suspected deep tissue injury: depth unknown
-Purple or maroon localized area of discolored intact skin or blood-filled blisterdue to damage of underlying soft tissue from pressure and/orshear.
-The areamay be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooleras compared to adjacent tissue.
-Deep tissue injury may be difficult to detect inindividuals with dark skin tones.
-Evolution may include a thin blister over a darkwound bed. The wound may further evolve and become covered by thin eschar
-Evolution may be rapid exposing additional layers of tissue even with optimaltreatment.
dark skin considerations
-!Stage I injury
-Discoloration
-Warmth
-Induration
-Hardness of skin
-!Deep tissue injury may also be difficult to detect in patients with more deeply pigmented skin.
-Erythema can be subtle in darker skin and may appear as a slightly different color, or the skin may be slightly darker than normal.
pressure injury prevention
-prone positioning in ARDS
-Special consideration to:
-Head
-Torso
-Legs
-Breast and genitalia
pressure injuries
-Diabetes mellitus- neurotrophic and vascular ulcers
-Dry skin -> moisturize
-you can also get it from pts sitting in urine (diff type of wet)
-Fungal skin infection
-Hypertensive ischemic ulceration
-Peripheral atheromatous emboli
-Peripheral vascular disease
-Self-inflicted trauma
-Venous stasis diseases
-It is difficult to detect stage 1 ulcers in darker-skinned individuals. When eschar is present, the ulcer cannot be accurately staged. Pressure ulcers under casts, braces, and support stockings can be easily missed. Those devices that can be easily removed for inspection of the skin should be removed on a regular basis. For casts, you must be alert to patient complaints of pain or clinical changes on exam of the extremity and remove the cast if necessary to inspect the skin1.
site of ulcer
-Most common site - Sacrum
-Second most common- Heel
-Areas over bony prominences
-Head, elbows, ears, trochanters, ischial tuberosities, lateral malleoli,
pressure ulcer prevention guidelines
-Use a risk assessment protocol
-Provide basic skin care
-Use a repositioning protocol for immobilized patients
-Use a pressure-relieving surface for at-risk patients
-Avoid friction and shear forces
-Maintain good nutrition
-Maintain mobility
-Use a systematic approach to evaluation and care
