Skin Integrity 2 Flashcards
pressure ulcers
also called pressure injury
- localized injury to skin and/or underlying tissues
– usually over bony prominences
– most common on sacrum and heels
- results from prolonged pressure or pressure in combination with shearing forces
- can be injury related to medical or other devices
- will generally heal by secondary intention
bony prominences (pressure ulcer sites)
- occipital bone
- scapula
- spinous processes
- elbow
- iliac crest
- sacrum
- ischium
- achilles tendon
- heel
- sole
- ear
- shoulder
- anterior iliac spine
- trochanter
- thigh
- medial knee
- lateral knee
- lower leg
- medial malleolus
- lateral malleolus
- lateral edge of foot
- posterior knee
pathophysiology of pressure ulcer
(capillaries have pressure on them, are occluded, causing cell death)
pressure on body for prolonged period of time –> stops capillary flow to tissues –>
deprives tissues of oxygen and nutrients –>
cell death + tissue necrosis
influencing factors
- pressure intensity: amount of pressure
- pressure duration: length of time pressure is exerted on the skin
- tissue tolerance factors: ability of tissue to tolerate the pressure, nutrition, perfusion, co-morbidities, condition of soft tissue
- shearing forces: when skin adheres to a surface and skin layers slide in direction of body movement
- moisture: excessive moisture that leads to skin breakdown
risk factors
- advanced age
- anemia: lack of oxygen to tissue bc oxygen travels on RBC and low RBC
- diabetes
- elevated body temperature: more sweating, moisture
- friction
- immobility
- impaired circulation
- incontinence
- low diastolic BP (less than 60 mmHg): not getting enough perfusion so tissues aren’t getting enough oxygen
- mental deterioration: may have restraints and bed alarm so aren’t getting up and walking
- neurologic disorders: not getting up and walking
- obesity
- pain: not getting up and walking
- prolonged surgery: laying one way for long time means reddened area
- vascular disease
clinical manifestations
- depends on extent of tissue involved
- staged/categorized based on visible or palpable tissue in the ulcer bed
- staging is based on the National Pressure Ulcer Advisory Panel (NPUAP) guidelines
- stage 1 (minor) to stage 4 (severe)
- presence of slough or eschar may prevent staging until it is removed
suspected deep tissue injury
INTACT SKIN
- purple or maroon localized area of discolored intact skin or blood-filled blister
- indicates damage of underlying soft tissue from pressure and/or shear
- may be preceded by tissue that is painful, firm, mushy, or boggy
- may be difficult to detect in patients with dark skin tones
skin assessment for patients with dark skin
- darker areas of skin: look for areas of skin that are darker than surrounding skin, these may appear purple, brown or blue
- skin temperature: use your hand to assess skin. an ulceration may feel warm initially, then become cooler with time.
- skin/tissue consistence: apply gentle pressure to common sites of injury to feel consistency. boggy or edematous tissue may indicate a stage 1 pressure ulcer.
- patient sensation: patients may also report pain or itchy sensation.
(look at where edges may be and look for color difference, any differencs in temp, sensation and consistency)
stage 1 pressure ulcer
- intact skin: non-blanchable redness of a localized area
- common over bony prominence
- may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
- darkly pigmented skin may not have visible blanching, but color may differ from the surrounding area
stage 2 pressure ulcer
LOST THE EPIDERMIS (from 1 to 2)
- partial-thickness loss of dermis
- shallow open ulcer with red/pink wound bed
- may also present as an intact or ruptured serum-filled blister
- can be a shiny or dry shallow ulcer without slough or bruising
- adipose (fat) is not visible, and deeper tissues are not visible
- granulation tissue, slough, and eschar are not present
stage 3 pressure ulcer
LOST THE DERMIS, can see subq tissue
- full-thickness skin loss
- subcutaneous tissue may be visible, but bone, tendon or muscle are not
- presents as deep crater with possible undermining of adjacent tissue
- ulcer depth varies by location, depending on depth of tissue in that area
stage 4 pressure ulcer
- full-thickness loss, extends to muscle, bone, or supporting structures
- bone, tendon, or muscle may be visible or palpable
- slough or eschar may be present on some parts of wound bed
- undermining (wound goes underneath skin to the side) and tunneling (deep towards the bone it goes) may also occur
unstageable ulcer
- full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
- slough may be yellow, tan, green, grey, or brown
- eschar may be tan, brown, or black in the wound bed
- slough or eschar may be removed to expose the base of the wound in order to stage
- note: stable, dry eschar on heels should not be removed
(typically not debrided bc don’t know how far down it goes)
complications of pressure ulcers
(infection is #1 complication to avoid)
- infection:
– leukocytosis: why WBCs increase count
– fever
– increased ulcer size, odor, or drainage
– necrotic tissue
– indurated, warm, painful
- untreated ulcers may lead to cellulitis, with spread of inflammation/infection to subcutaneous tissue, connective tissue, bone (osteomyelitis), can lead to sepsis and death
- most common complication is recurrence of tissue breakdown/repeat pressure ulcers.
complications of pressure injuries details
- recurrence of tissue breakdown/repeat pressure injuries
- infection: signs of infection include swelling, redness, and foul odor **
– leukocytosis **
– fever **
– necrotic tissue **
– increased injury size, odor, or drainage ** - cellulitis: can lead to sepsis and death
nurses play a critical role in the prevention and treatment
- assess skin of every patient on admission and every shift
- assess all patients for risk for skin breakdown every 12 hours
- stage 3 and 4 pressure injuries acquired after admission: never want to happen
pressure ulcer prevention
- pressure redistribution
- keep skin dry: if incontinent clean with no-rinse perineal cleaner and supply barrier ointment
- reposition:
– drawsheet or transfer board
– position patient at 30 degrees lateral position
– HOB at 30 degrees or less
– trapeze bar - turning schedule
- nutrition and fluid intake
care planning
- prevent deterioration
- reduce factors that contribute to pressure and skin breakdown
- prevent infection
- promote healing
- prevent recurrence
what to do when patient has pressure injury
- document stage, size, location, exudate, infection, pain and tissue appearance
- some facilities require pictures of pressure ulcer in EMR, have special cameras
- wound care specialists will determine specific cleansing protocol and which types of dressings are appropriate, but general principles:
– clean with normal saline to avoid damaging cells
– keep slightly moist to encourage re-epithelialization - surgical treatment may be necessary: skin grafts, skin flaps, or musculocutaneous flaps are all surgical interventions to aid in healing
patient and family teaching
- teach prevention techniques to patient and caregivers, including early signs of skin breakdown and tissue injury
- continued nutritional support
- pressure ulcer care techniques, wound care at home
- turning schedule
lower extremity ulcers
- different pathophysiology from pressure ulcers
- in general, related to changes in blood flow to lower extremities due to chronic disease processes
arterial ulcers
- peripheral artery disease (PAD) causes problems with blood flow in arteries, becoming narrow or blocked, usually caused by atherosclerosis
- ulcers are caused by ischemia and nutrition deprivation as a result of decreased circulation
- skin will be thin, shiny, and dry, with loss of hair on ankles, feet
- those with atherosclerosis, PVD, diabetes, smoking, hypertension, advanced age, obesity, and cardiovascular disease are at increased risk
arterial ulcers details
(pale, even margins, deep, very painful)
- may be found between toes or on tips of toes, on phalangeal head, lateral malleolus, or areas with rubbing footwear
- even wound margins, punched-out appearance, pale, deep wound bed
- extremely painful, with minimal exudate
- must revascularize with stents to treat ischemia, then topical treatments will help with healing ulcer
venous leg ulcers
- venous insufficiency occurs when blood cannot flow upward from veins in the legs
- chronic venous insufficiency occurs when valves are damaged, allowing blood to leak backward, resulting in venous stasis
- those with obesity, deep vein thrombosis (DVT), pregnancy, incompetent valves, congestive heart failure (CHF), muscle weakness, decreased activity, advanced age, and family history are at increased risk
