Pressure Ulcers Flashcards
Pressure injury (ulcer)
- Localized area of soft tissue injury
- Caused by unrelieved pressure
- Usually located over bony prominences
- Results in damage to underlying tissue
Ischemia
- Occurs when external pressure exceeds capillary pressure
- 12-32 mmHg
- Inverse relationship between pressure and time to ulceration
Variables to pressure injuries
- Pressure
- Shear
- Moisture
- Friction
- Underlying soft tissue more susceptible to pressure than skin ie. Muscle
60,000 deaths annually due to
Pressure injuries
Medicare incentive for appropriate pressure injury treatment
No longer will reimburse hospitals for treatment of new pressure sores but will reimburse at a higher rate if ulcer is noted within 2 days of admission
Sacrum
Most common site for pressure injury, avoid slouching in bed or chair
Heels
Second most common site for pressure injury
- Immobile or numb legs, leg traction
- Higher risk in persons with peripheral vascular disease, hip fracture, and neuropathy from diabetes
Trochanter
- Hip bone location for pressure injury
- Side-lying, contractures patients at highest risk
Lateral foot
Location of pressure injury, seen in patients in prolonged side lying with rotated foot
Ischium
Location for pressure injury
- Sit here when erect
- Paraplegics at highest risk
Staging of pressure injuries
- Used to describe extent of tissue involvement in the ulcer
- Stage I, II, III, IV and unstageable
- Deeper tissues involved as stages increase
- You do not down-stage as the wound heals*
Stage I pressure injury
- Defined area of persistent redness (non-blanchable erythema) in lightly pigmented skin
- May appear with persistent red, blue, or purple hues in persons with darker skin tones
- Compared to surrounding skin, area may be warmer or cooler, firm or boggy, painful or itchy
No open area in the skin
Detecting stage I pressure injury
- With each repositioning inspection bony prominences on which person was lying
- Inspection at least needs to be daily
- Treatment must start promptly via documentation and pressure relief
- Inspection of heels -> use mirror if needed
Stage II pressure injury
- Partial thickness skin loss involving epidermis and/or portions of the dermis
- Ulcer is superficial
- Appears like an abrasion or blister with normal surrounding skin
Detecting stage II pressure injury
- Inspect skin for shallow wounds or shiny areas of skin loss
- Do not classify skin tears, erosion from urine or feces as this stage
- Do not include wounds covered with slough where deeper regions are suspected
Stage III pressure injury
- Full thickness skin loss (epidermis and dermis missing)
- Damage or necrosis of subcutaneous tissue
- May extend down to but not through underlying fascia
- Ulcer bed may be subcutaneous fat, slough, necrosis or granulation tissue
- A deep crater with or without undermining of adjacent tissue
Detecting stage III pressure injury
- Inspect all skin for wound
- Do not label deep wounds covered with nonviable tissue as this stage
- Look for evidence of infection in ulcer; redness, swelling, pain, warmth, exudate
Stage IV pressure injury
- Full thickness loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures ie. Tendon, joint capsule
- Often associated with tunneling or undermining
- May or may not have slough or eschar
Detecting stage IV pressure injury
- Inspect all skin for wounds
- Palpate or gently probe with sterile applicator to feel for bone
- Do not label ulcers covered with necrotic tissue as this stage
Undermining
An area of the ulcer beneath the skin surface that extends under the edge of the wound
Tunneling
- Narrow extension into the surrounding tissue from the sides of an ulcer
- Also called sinus tracts
Fistula
A tunnel or sinus tract that ends in another structure or hollow viscous
Unstageable pressure ulcer
Ulcer is covered with eschar or slough and the true base of the wound cannot be seen (depth)
Deep tissue injury
- A pressure related wound that begins in subdermal tissue
- Initially appears purple or blue, usually leads to denuding (removal or loss) of the epidermis and eschar formation
- Do not stage as stage I pressure injury
- Likely cause; prolonged sitting on commode or donut shaped objects
When to stage a pressure injury
- At the time of initial assessment or if an ulcer deteriorates (the highest stage defines the wound)
- When improving label ulcer with original stage as healing (healing stage III)
- Do not document as stage II once it has started to heal (no down-staging)
- Stages do NOT indicate progression of ulcer development OR healing
Essential elements to pressure injury assessment
- Site
- Stage
- Depth
- Type of tissue exposed
- Surrounding skin
- Tunneling, undermining
- Pain
- Exudate
Measure depth of pressure injury
- Use sterile applicators to probe the wound
- Tunneling and undermining with require dressings to reach these areas
- Plan to fill all dead space with dressings
- If area not filled, false roof can develop
Erythema
Redness
Maceration
Softening and breakdown of tissue due to prolonged exposure to moisture
Edema
Swelling, fluid accumulation
Tape injury
Due to application and removal of adhesives
Induration
Thickening and hardening of skin, inflammatory process
Fluctuance
Wavy impulse during palpation
Pressure injury treatment
- Pressure reduction/relief
- Debridement of nonviable tissue
- Cleansing
- Modalities
- Dressings
- Nutritional consult
- Surgical consult
Surgical intervention for pressure injury treatment
Flap used
Primary ideas for pressure relief
- Pressure redistribution
- Relief and elimination (no pressure)
- Isch-dish; provided relief of ischium
Active mattresses for pressure relief
Powered with or without load
Reactive mattresses for pressure relief
Redistribute pressure when load is applied
Physical therapy role in treatment of pressure injuries
- Reposition bed-bound persons at least every 2 hours and chair-bound persons every 1 hour
- Teach chair-bound persons to shit weight every 15 minutes if able
- Avoid using donut-type devises and sheepskin for pressure redistribution
- Use lifting devised (trapeze or bed linen) to move persons rather than drag them during transfers/position changes
- Use pillow or foam wedges to keep bony prominences from direct contact with each other
- Avoid positioning directly on the trochanter when using side-lying positions; use the 30 degree lateral inclined position
- Maintain the head of the bed at or below 30 degrees
- Institute rehab program to maintain or improve mobility/activity status
