Pressure Injury Management

Question 0

What is interface pressure?

Answer 0

Pressure exerted on the skin surface when in contact with a support surface (e.g holding a plank)

Greater body surface area= lower uniform pressure
Lesser body surface area= higher point pressure

Question 1

What is a pressure injury?

Answer 1

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

Question 2

Discuss the aetiology of a pressure injury

Answer 2

-Vessel occlusion > tissue hypoxia > pallor > ischaemia > increased capillary permeability > accumulation of metabolic wastes/proteins in interstitial space > oedema > impairs tissue and perfusion > ischaemia = PI.
-Excessive or sustained compression of the vascular and lymphatic network
- compression of capillaries or micro circulation
-compression exceeds perfusion pressure and structural resistance of capillaries = oxygen and nutrient supply to tissue is compromised.
Results in localised ischaemia, hypoxia, acidosis, oedema and necrosis

Question 3

What degree of pressure collapses capillary walls?

Answer 3

32mmhg - will vary among people depending on vessel structure, adipose deposition over bony parts, BP and general health

Question 4

What are the common diets for pressure area injuries?

Answer 4

On side: Maleoli, shoulder, ear cartilage, trochanter, metatarsal
Sitting: scapular,sacrum, ischium,
On back: occiput, scapular, spinous process,heel, elbow, iliac crests

Question 5

Name and describe the two mechanisms by which a pressure injury is caused?

Answer 5

Sheer: parallel pressure applied to sliding body against a non conform able surface causes tissue damage.
- distorts tissue causing two adjacent internal tissues to deform in transverse plane.
Friction: rapid or frequent movement against an abrasive surface
- rubbing of one surface against another ; or the force that resists the relative motion of two objects that are touching

Question 6

What are the predisposing INTRINSIC risk factors for pressure injuries?

Answer 6

Pertains to the person
Alter the ability of skin and underlying tissue to resist pressure, shear, friction and compromises recovery.

Advanced age, immobility and inactivity, malnutrition, skin temperature and PH, chronic illness.

Question 7

What are the predisposing extrinsic factors for pressure injury development?

Answer 7

Pertain to external environment
Increase susceptibility of skin to damage.
-pressure, shear and friction, moisture

Question 8

Discuss how advanced age is a risk factor for pressure injuries

Answer 8

Deterioration of body function and healing potential
Loss of SC tissue, collagen production-assists with tissue support and production.
Impaired mobility and activity by physical, cognitive or neurological problems.
Poor nutrition or access to it - reduced immunity, poor tissue turgor, in elasticity of skin.

Question 9

Discuss how immobility and activity are risk factors for pressure injuries

Answer 9

Affect ability to independently re-position and offload tissue.
Susceptible to shear and friction if assistance is required.
Impairs blood flow and retards venous return =oedema= compromises 02 of skin

Question 10

Discuss how malnutrition effects pressure injury development

Answer 10

Balance diet optimises health,healing,immune response.
Obese people have poorly vascularised tissue due to excess adipose, capillaries vulnerable to shear
Obesity compromises movement
Cachexic people have bony parts with reduced tolerance for pressure.

Question 11

Discuss how skin temperature and PH are a predisposing factor for pressure injuries

Answer 11

Skin provides protection and thermoregulation
Changes in skin temp are closely aligned to changes in core temp
One degree rise raises metabolic needs by 10%
PH of skin is acidic at 5.5ish -optimise microclimate
Microclimate = skin temp, humidity and moisture
Acidic minimises bacterial colonisation and opportunistic infection

Question 12

Describe how chronic illness is a risk factor for pressure injuries

Answer 12

Diabetes, carcinoma, peripheral artery disease, CPD, lymphodoema, real/ hepatic impairment, HTN, anaemia
Smoking

Question 13

Discuss pressure, shear and friction as risk factors for pressure injuries

Answer 13

Duration and magnitude of pressure= degree of damage
High pressure= damage in short time
Greater body surface = lower uniform pressure and vice versa.
Interface pressure- pressure exerted at the skin surface when in contact with a support surface.
When IP exceeds capillary closing pressure, damage occurs.
IP= body weight/ surface area supported
Shear and friction are interlinked

Question 14

Discuss how moisture is a factor affecting pressure injuries

Answer 14

Tensile strength is impaired with frequent/excessive moisture
Maceration
Increase in skin temp ams humidity increase moisture amount

Question 15

List the pressure injury measurement stages

Answer 15

Braden, Norton and waterlow are validated. Also gosnell and ramstadius

Question 16

Describe the Nortons measurement scale

Answer 16

Five main risk factors: 
- general physical condition
-mental state 
-activity
-mobility
-incontinence
These are broken down into sub categories that assess risk

Question 17

Discuss the waterlow pressure ulcer prevention policy

Answer 17

Risk scale on one side , guidelines for management on the other.
11 parameters 
Several score parameter can be used 
20+ = at VH risk
Pg 253

Question 18

Discuss the Braden scale for predicting pressure sore risk

Answer 18

6 parameters;
Sensory perception
Moisture
Activity
Mobility
Nutrition 
Friction and shear
3-4 sub categories 
Low score = high risk

Question 19

Discuss the ramstadius pressure ulcer risk assessment tool

Answer 19

Non-numerical
Direct assessment and intervention
Considered algorithm
Pg 255

Question 20

Describe a stage 1 pressure injury

Answer 20

• Intact skin with non-blanchable redness of a localised area, usually over a bony prominence.
• darkly pigmented skin, colour may differ from surrounding area
• painful,firm,soft, warmer or cooler compared to adjacent tissue
• may indicate “at risk” persons

Question 21

Describe a stage 2 pressure injury

Answer 21

• Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
• May also present as an intact or open ruptured blister
• shiny or dry shallow ulcer without Slough or bruising
• stage 2 should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Question 22

Describe a stage 3 pressure ulcer

Answer 22

• full thickness tissue loss
• SC fat may be visible but bone, tendon and muscle are not exposed
• May include undermining or tunnelling
• the depth of a stage 3 varies
• bridge of nose, ear, occiput and malleolus do not have SC tissue and stage 3 can be shallow
• in contrast areas high in adipose can be extremely deep stage 3

Question 23

Describe a stage 4 pressure ulcer

Answer 23

• full thickness tissue loss WITH exposed bone , tendon or muscle.
• Slough or Eschar may be present on some parts of the wound bed.

Question 24

Describe an unstageable pressure injury

Answer 24

``` Full thickness tissue loss in which the base is covered in Slough or Eschar Until enough slough/Eschar can be removed the PI cannot be determined. Stable Eschar (dry, adherent intact without erythema) on heels. Serves as the body's natural cover and should not be removed ```

Question 25

Describe a suspected deep tissue injury.

Answer 25

Purple localised area of discoloured intact skin or blood filled blister due to damage of underlying skin. Soft tissue from pressure and/ or sheer. May be painful, firm,mushy,boggy, warmer or cooler Evolution may be rapid exposing additional layers of tissue

Question 26

What are prevention methods for pressure injuries?

Answer 26

Education: understand causes, asses self car ability, verbal and written advice, safe methods for repositioning, signs & symptoms. Skin care: maintain normal acidic ph, optimise microclimate, regular and gentle skin care, avoid alkaline soaps and cleansers, use fragrance free ph neutral, use skin barrier creams and films. Repositioning: time frame suitable to patient not routine, routine skin inspections on repositioning, protect bony parts, 30 degree lateral position for supine, use support devices to hold positions,passive and elective exercises. Nutrition : keep hydrated, nutritional supplements Dressings for skin protection: hydro colloids with or without foam, foam, sheet hurdle gels, silicone skin care pads.

Question 27

What pressure injury scale has the best inter rarer reliability

Answer 27

Braden's Scale

Question 28

What is reactive hyperaemia?

Answer 28

Rapid capillary refill after pressure is removed Normal response, subsides in 5-20mins Over compensation for low 02 and nutrients

Question 29

What is non- blanching hyperaemia?

Answer 29

Red area that doesn't turn white Microvascular system is compromised Inflammatory changes are now present Non blanching hyperaemia present after 30 mins > stage 1 ulcer

Question 30

What is blanching hyperaemia?

Answer 30

Area that turns white under pressure Warning signs for PI, needs to be treated to avoid damage Hard to detect in white skin

Question 31

Discuss PI management

Answer 31

``` Cleanse peri wound skin and PI when dressing are changed Debride as indicated Wound dressings Eliminate cause Educate Increase mobility Limit smoking Balanced diet Skin hygiene Moisture management Repositioning ```

Question 32

How would you assess a pressure injury?

Answer 32

``` Assess intrinsic and extrinsic factors Location Clinical appearance ; - Eschar, slough tendon, bone,granulation, epithelialisation, infection. Exudate; -type, colour, amount, consistency State of surrounding skin; - erythema, oedema, blanching, bruising, maceration, lesions. Palate for warmth, tenderness, cap refill, pulses Dimensions; - circumference, depth, width, length Tissue loss; Stage of PI ```

Question 33

What are alternating pressure relieving systems

Answer 33

-automatically transfer pressure loading - alternating pressure points allows capillary recovery - dynamic or static modes Immobile, cachectic, obsess Advantages: high pressure relief, decreases frequency for repositioning, reduces shear and friction, reduce heat and moisture. Disadvantages: costly, special laundering, electrical or battery supply, regular maintenance, noisy, mvmt May concern pts

Question 34

What are the 3 types of speciality beds?

Answer 34

High air loss: Air fluidised systems- dynamic for large areas of tissues. Warm air pumped through bath shaped beds containing beads, beads create constant movement. Pulsating air suspension therapy: Pressure relief and capillary circulation and lymph drainage to reduce odema. Not suitable for spinal precautions . ``` Kinetic therapy beds: Gentle continuos oscillation or rotation Prevent PI's , venous stasis,DVT Not suitable for spinal or raised ICP Feeling of insecurity during movement ```

Question 35

Discuss static, non powered, or reactive Low pressure SS

Answer 35

High density, Low resistance foams, or contain polyester fibre, air or gel mediums. Allows greater conformibility

Question 36

Discuss powered or reactive constant low pressure SS

Answer 36

Allows greater conformibility = greater load bearing interface Low air loss system built in- allows air to escape from micro perforations Reduces heat and moisture on skin

Question 37

Define a support surface (SS)

Answer 37

Specialised device for pressure redistribution designed for management of tissue loads, micro climate and/or other therapeutic functions E.g mattress,trolley, overlays, mattress replacement, bed frames, cushion overlays and replacements

Question 38

What factors should you consider when selecting a support surface?

Answer 38

Patient: risk score, weight,height,BMI, mobility, comfort preferences Environmental: shear, friction, pressure and microclimate Equipment: weight and height limits, pressure redistribution properties, waterproof, bactericidal and fire retardant properties. Local availability and cost.