Pressure Injury Flashcards
Define a pressure injury
A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction
Aetiology of pressure injuries
1) intensity - capillary pressure and capillary closing pressure
2) Duration
3) Tissue tolerance
What can increase pressure?
1) Impaired mobility
2) Impaired activity
3) Impaired sensory perception
Extrinsic factors that contribute to pressure injuries
Moisture
Shear
Friction
Intrinsic
Nutrition Demographics Oxygen delivery Skin temperature Chronic illness
Define interface pressure
Interface pressure is the pressure exerted on the skin surface when in contact with a support surface
Common sites for a pressure injury
Scapular Sacrum Ischium Occiput Elbow Iliac crest Heel Ear cartilage Shoulder Malleoli
Define shear, friction and forces
Shear - moving skin
Friction - heat
Forces - pressure
Definition of shearing
Parallel pressure applied to a sliding body against a non-conformable surface causes tissue damage
Definition of friction
Friction is rapid or frequent movement against an abrasive surface
Define blanching
Skin that whitens under compression due to local occlusion or vasoconstriction of the bloody supply
Define reactive hyperaemia
When pressure is removed from a compressed area of tissue the capillaries rapidly refill and dilate overcompensating for deficiencies in oxygen and nutrients, which causes a red flushing of the tissues.
Define non-blanching hyperaemia
A reddened area of skin that does not turn white under finger pressure
Define a stage 1 pressure area
1) intact skin with non-blanchable redness of a localised area
2) May be painful, firm or soft
Define stage 2 pressure injury
1) partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough
2) May also present as an intact or open blister
3) without slough or bruising
Define a stage 3 pressure injury
1) full thickness tissue loss
2) subcutaneous fat may be visible
3) Slough may be present but does not obscure the depth of the tissue
4) May include undermining or tunnelling
Define a stage 4 pressure area
1) full thickness tissue loss with exposed bone tendon or muscle
2) Slough or Escher may be present on some parts of the wound bed
3) can extend into supporting structures (joint capsule, fascia or tendon)
Define an unstageable pressure area
1) full thickness tissue tissue loss in which the base of the ulcer is covered by Slough and/or Escher in the PI bed
2) until enough Slough and/or Eschar is removed to expose the base of the wound, the stage can not be determined
Define a suspected deep tissue injury
1) purple or maroon localised area of discoloured intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear
2) tissue can be painful, firm, mushy, boggy or warmer
3) evolution may include a thin blister over a dark wound bed
4) The PI may further evolve and become covered with thin Eschar
What are predisposing factors for pressure injuries?
1) chronic illness - diabetes, matastatic carcinoma, renal impairment and lymphoedema
2) conditions that impact on tissue perfusion - smoking, peripheral vascular disease, hypotension, blood dyscrasis
3) impaired sensation and cognition
What are the treatment options for pressure injury?
1) manage on a pressure relieving device
2) manage pain
3) regular repositioning
4) high protein diet
5) nutritional supplementation
How can shear and friction be reduced?
1) maintain head of bed elevation at 30 degrees
2) appropriate use of transfer aids
3) ensure all contact surfaces, garments and linen are non-abrasive and do nit hinder activity and mobility
What are the principles of skin care in relation to pressure injuries?
1) skin assessment daily (within 8 hours of admission)
2) skin hygiene
3) skin moisture maintenance
4) maintenance of stable skin temperature and pH
5) optimise nutritional and fluid intake
What is the ideal support surface?
1) comfort and conformity
2) optimal pressure redistribution
3) no bottoming out
4) impermeable and fire retardant
5) water proof
6) non-permeable to bacteria
7) emergency features - CPR deflation
