Pressure Injurys Flashcards
What is a pressure injury?
A localised damage to the skin and underlying soft tissue thats usually, but not always, over a body prominence
What type of devices can pressure injurys be caused by?
External medical devices, these wounds are then referred to as medical device-related pressure injurys (MDRPIs)
Can mucous membranes (such as the nose, mouth, lungs, and stomach) sustain pressure injurys?
Yes. Although the anatomy of mucous membrane sites isn’t consistent with pressure injury staging guidelines. For this reason, pressure injuries to mucous membranes can’t be staged using the pressure injury staging system.
What are two examples of where mucous membranes can (such as the nose, mouth, lungs, and stomach) sustain pressure injurys?
- From endotracheal tubes
2. From nasogastric tube stabilisers
When does shear occur?
When layers of tissue move in opposite, parallel directions, resulting in stretching, occluding or the tearing of blood vessels and disruption of blood flow to the affected area.
Disrupted blood flow can lead to what?
Tissue ischemia and tissue death
How long can it take to notice a shear injury?
It can take several days for the tissue damage to ‘surface’ and show itself, typically by changes in colour, temperature, and texture
Pressure injurys are staged using what system?
The NPUAP staging system
Do we backstage pressure injurys? I.e saying that an S3PI is healing to an S2PI?
No, once a pressure injury is characterised i.e “S3PI”, it is always that, it can either be a healing S3PI or a non-healing S3PI. If a wound is worsening it can be restaged.
What does HAPIs stand for?
Hospital-acquired pressure injuries
What are the disadvantaged for a patient with a HAPIs?
Higher mortality rate, longer length of stay, and a higher chance of readmission + increased cost of care.
Determining the stage of a pressure injury comes down to what factors?
Presence of fluid in the wound
Colour of the area
Type of tissue exposed or directly palpable.
What are some things we can do as nurses to prevent a HAPI?
Turning and repositioning the patient frequently
Padding bony prominences (pillow between knees ect)
Keeping the elevation of the head at 30 degrees
Ensuring the surface the patient is on allows them to move side to side
Floating the heels off the mattress
Promoting PH-balances skin cleansers followed by moisturisers and protectants
Containing fecal and urinary incontinence to the best we can (pads)
Optimising patients nutritional status
Provide a pressure redistribution mattress and chair pad for those at high risk
Assess for tissue breakdown
Collaborate with the MDT to optimize care interventions.
