Skin Integrity Flashcards
What are pressure injuries also referred to as?
Pressure ulcers
Pressure sores
Bed sores
Decubitus ulcer
What is the definition of a pressure injury?
Localized damage to skin or underlying soft tissue usually over a bony prominence typically related to a medical device
The result of intense or prolonged pressure or pressure in combination with shear
How can a pressure injury present?
As intact skin
Open ulcer
T/F: pressure injuries do not occur on mucous membranes
False. Pressure sores can occur on mucous membranes on the lips, oral mucosa, tongue or inside the nares
What are pressure sores the result of?
A combination of pressure, temperature, surface moisture/humidity and airflow
What can affect the tolerance of soft tissue for pressure and shear?
Microclimate
Nutrition
Perfusion
Comorbidities
Condition of soft tissue
What is the first stage of pressure injuries?
Intact skin with non-blanchable redness
Changes in sensation, temperature or firmness may precede visual changes
What is the second stage of pressure injuries?
Partial thickness loss of skin involving epidermis and dermis
Presents as intact or open serum filled blister or crater
Which tissues are especially vulnerable to pressure sores from medical devices?
Mucosal medications
T/F: pressure injuries are not usually preventable
False. Pressure injuries are frequently avoidable
What is does MDRPI mean?
Medical device related pressure injury
What are the risks associated with hospital acquired pressure injuries?
Extend length of stay
Decreased health related quality of life
Increased risk of mortality
Increase 30 day readmission rate
Increase cost of patient care
What are medical devices that are frequently responsible for pressure injuries?
Nasogastric tubes
Orogastric tubes
Foley catheters
Ostomy tubes
Surgical drainis
Cervical collars
Casts
Where would NIV masks cause pressure sores?
Bridge of nose
Bony prominences
Anywhere that mask interface or head gear come in contact with skin
Where would endotracheal tubes cause pressure sores?
Lips
Tongue
Corners of mouth
Underneath tape/straps
Under ears
Back of neck
Where do ET tube holders cause pressure sores?
Lips
Cheeks
Ears
Back of neck
Skin above lips
Where would bite blocks cause pressure sores?
Mouth
Lips
Tongue
Where could tracheostomy tubes cause pressure sores?
Skin under the flange
Where could a HHFNC cause pressure sores?
Nares
Bony prominences of cheeks
Ears
Where could pulse oximeters cause pressure sores?
Under probe site on fingers, toes or ears
Where can a nasal cannula cause pressure sores?
Nares
Behind ears
Under chin
Where can facemasks and trach collars cause pressure sores?
Under mask straps
Contact points on nose face and neck
Where can CPAP masks cause pressure sores?
Circumscribing nose
Bridge of nose
Nares
Chin
Who is at the greatest risk for developing pressure sores?
Chronically steroid dependent
Patients on vasopressors
Have fragile and edematous skin
Why are people who are chronically steroid dependent at greater risk for pressure sores?
Steroids slow process of wound healing
Why do patients on vasopressors have a greater risk for pressure sores?
They will have a lower blood pressure making it easier to cut off blood supply to surrounding tissue
What patients are generally chronically steroid dependent?
Asthma
Osteoarthritis
Rheumatoid arthritis
Crohn’s disease
IBS
Which patients may have fragile or edematous skin?
Elderly
Tissue edema
Septic shock
What mechanical forces exasperate pressure sore formation?
Pressure
Shear
Friction
Moisture
What can shearing forces do to the tissue?
Stretching, kinking and tearing of vessels in the subcutaneous tissues leading to deeper necrosis
How does moisture exacerbate skin breakdown?
Moist skin compromises tissue strength and increases risk of breakdown when exposed to pressure and shear
What can cause the skin to become moist?
Perspiration
Wound drainage
How can we reduce skin moisture?
Clean skin routinely
Use products that are absorbent and wick moisture away from skin
What are protective options to prevent skin breakdown?
Gecko gel pad
Sleep comfort nasal pad
Mepilex foam
Ear protector tubing
Skin barrier lotion/topical steroids
How long should protective skin barriers be changed?
When dirty
Between 3-7 days depending on site conditions
T/F: gauze is an acceptable skin protective barrier
False. Never use gauze as a skin protective barrier
When using a mask for NIV, what can you do to avoid pressure sores?
Use skin protective barriers
Rotate mask types
How tight should an NIV mask be?
Should be able to fit 2 fingers under the strap
Why should you avoid lifting 1 side of the mask?
Increases risk of injury from shearing forces
How do we prevent pressure sores for patients who are intubated?
Move position and check lips/mouth every 4 hours
Why should you limit the the number of on/off maneuvers performed when patients are wearing masks?
Limit risk of injury due to shear and friction
What can you do to limit the number of on/off procedures for patients on NIV?
Communicate, collaborate and cluster care to minimize on/offs
Describe how to remove NIV masks
Reverse of application
Remove side clips simultaneously and lift mask from the chin upwards
How should the ETT stabilizer strip be positioned?
Should not be tough lips
How should the commercial tube holder be set up to avoid pressure injuries?
Dont let straps compress ears
2 finger tightness
Change straps if wet, soiled and/or bloody
How tight should trach tubes be?
Fit 1 finger underneath
How often should oximetry probes be moved?
Every 2 hours
Describe the controversy associated with bed angle and pressure sores
> 30 degrees reduces chances of VAP
<30 degrees reduces changes of compressive pressure on the sacrum
What can result from hospital acquired pressure injuries?
Extend length of stay
Increase cost of patient care
Increase risk of mortality
Increase 30 day readmission rate
Decrease heath related quality of life
Pressure injuries result from a combination of excess
Pressure
Temperature
Surface Moisture
T/F: Patients should have a zero leak from their NIV mask
False
What can happen during shearing to blood vessels?
Stretching
Kinked
Torn
During a hand-off, what information about skin breakdown should be communicated?
patients skin integrity
strategies for prevention
patient risk factors
What do secretions or wound drainage on the skin around the tracheostomy site lead to
a decrease in skin integrity
How can a pressure injury present?
As intact skin
As an open ulcer
On the mucus membranes
T/F: the ETT stabilizer should not touch the patients lips
true
What are options for skin protective barriers?
Ear protector tubing
gecko gel pads
sleep comfort nasal pads
