Pressure Injury Management Flashcards
What is interface pressure?
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
What is 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
Discuss the aetiology of a pressure injury
-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
What degree of pressure collapses capillary walls?
32mmhg - will vary among people depending on vessel structure, adipose deposition over bony parts, BP and general health
What are the common diets for pressure area injuries?
On side: Maleoli, shoulder, ear cartilage, trochanter, metatarsal
Sitting: scapular,sacrum, ischium,
On back: occiput, scapular, spinous process,heel, elbow, iliac crests
Name and describe the two mechanisms by which a pressure injury is caused?
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
What are the predisposing INTRINSIC risk factors for pressure injuries?
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.
What are the predisposing extrinsic factors for pressure injury development?
Pertain to external environment
Increase susceptibility of skin to damage.
-pressure, shear and friction, moisture
Discuss how advanced age is a risk factor for pressure injuries
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.
Discuss how immobility and activity are risk factors for pressure injuries
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
Discuss how malnutrition effects pressure injury development
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.
Discuss how skin temperature and PH are a predisposing factor for pressure injuries
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
Describe how chronic illness is a risk factor for pressure injuries
Diabetes, carcinoma, peripheral artery disease, CPD, lymphodoema, real/ hepatic impairment, HTN, anaemia
Smoking
Discuss pressure, shear and friction as risk factors for pressure injuries
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
Discuss how moisture is a factor affecting pressure injuries
Tensile strength is impaired with frequent/excessive moisture
Maceration
Increase in skin temp ams humidity increase moisture amount
List the pressure injury measurement stages
Braden, Norton and waterlow are validated. Also gosnell and ramstadius
Describe the Nortons measurement scale
Five main risk factors: - general physical condition -mental state -activity -mobility -incontinence These are broken down into sub categories that assess risk
Discuss the waterlow pressure ulcer prevention policy
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
Discuss the Braden scale for predicting pressure sore risk
6 parameters; Sensory perception Moisture Activity Mobility Nutrition Friction and shear 3-4 sub categories Low score = high risk
Discuss the ramstadius pressure ulcer risk assessment tool
Non-numerical
Direct assessment and intervention
Considered algorithm
Pg 255
Describe a stage 1 pressure injury
- 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
Describe a stage 2 pressure injury
- 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.
Describe a stage 3 pressure ulcer
- 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
Describe a stage 4 pressure ulcer
- full thickness tissue loss WITH exposed bone , tendon or muscle.
- Slough or Eschar may be present on some parts of the wound bed.
Describe an unstageable pressure injury
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
Describe a suspected deep tissue injury.
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
What are prevention methods for pressure injuries?
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.
What pressure injury scale has the best inter rarer reliability
Braden’s Scale
What is reactive hyperaemia?
Rapid capillary refill after pressure is removed
Normal response, subsides in 5-20mins
Over compensation for low 02 and nutrients
What is non- blanching hyperaemia?
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
What is blanching hyperaemia?
Area that turns white under pressure
Warning signs for PI, needs to be treated to avoid damage
Hard to detect in white skin
Discuss PI management
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
How would you assess a pressure injury?
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
What are alternating pressure relieving systems
-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
What are the 3 types of speciality beds?
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
Discuss static, non powered, or reactive Low pressure SS
High density, Low resistance foams, or contain polyester fibre, air or gel mediums.
Allows greater conformibility
Discuss powered or reactive constant low pressure SS
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
Define a support surface (SS)
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
What factors should you consider when selecting a support surface?
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.
