Week 6: Pressure Injuries Flashcards
List some age-related changes that occur to the integumentary system?
- colour and pigmentations (sunspots)
- skin tags, keratosis (scaly spots)
- vascularity (bruising)
- turgor decreases
- thickness decreases (thin & translucent appearance, wrinkles, decreased subcutaneous fat)
- loss of moisture (dryness & flaking, decreased perspiration (sweating))
What are the functions of the integumentary system?
- thermoregulation
- protection of underlying structures
- cutaneous sensations
- stores fat
- excretion and absorption
- synthesis of Vitamin D
- forms a protective barrier against chemical and micro-organisms
Name the largest organ in the body?
Skin (in terms of area and weight both)
A localized injury to the skin and underlying tissue, usually over a bony prominence, as a result of pressure, shear, friction, or a combination of these factors and is affected by moisture, nutrition, perfusion, and comorbidities (more than 1 disease present at the same time)
Pressure ulcer
List the process in which pressure ulcers form?
Pressure –> tissue compression (pushing together) –> vascular obstruction —> interference with normal cell metabolism –> cell death
What 4 terms indicate tissue damage?
- hyperemia (normal)
- blanched hyperemia (not concerning)
- non-blanching (concerning as redness post hyperemia does not occur indicating blood not flowing back)
- ischemia (lack of blood supply indicating cell death)
Define hyperemia:
localized vasodilation caused by pressure manifested by reddened skin that is a compensatory response to lack of flow to underlying tissue
Define blanching hyperemia:
return of blood flow (redness) after blanching (pressing) on a surface; this is indicative of a transient (impermanent) hyperemia
Define non-blanching hyperemia:
- redness remains long after pressure is removed
- indicating a degree of microcirculatory disruption often associated with other clinical signs, such as blistering, induration (localized hardening of the tissue)
Define ischemia:
reduce blood flow to tissue that is under pressure; may result in tissue death
What does a Braden scale assess?
A risk assessment tool to assess patients for risk of skin breakdown.
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
What is the difference between friction and shear?
Friction - a force that occurs in a direction opposite of movement creating heat ( heels, elbow, back of head @ greatest risk)
Shear - when underlying bone and soft tissues above them move in the opposite directions; involves gravity and friction(coccyx @ greatest risk)
List the pressure points at risk in supine position:
- occiput (back of the head)
- scalpel (upper back)
- sacrum (lower back)
- heels
List the pressure points at risk in lateral position:
- ear
- acromion process (below shoulder)
- elbow
- trochanter (below the hip)
- medial & lateral condyle (below each knee)
- medial ad lateral malleolus (each ankle bone)
- heels
List the pressure points at risk in the prone position:
- elbow
- ear, cheek, nose
- breasts (female)
- genitalia (male)
- iliac crest (very top of thigh)
- patella (knee caps)
- toes
List the pressure points at risk for a patient in a wheelchair:
- hand, wrist, elbow
- back of the upper and lower arm
- shoulder blades and spine
- coccyx
- feet (heels and toes)
Pressure-relieving devices indicate that amount of pressure is calculated by:
Dividing force by area.
Pressure = Force/area
How can pressure injuries be prevented?
- Braden scale
- identify high-risk areas
- maintain mobility and activity
- use pressure-relieving devices
reposition q2h - adequate food and fluids
How can pressure injuries be managed?
- team approach
- reduce pressure (e.g elevate heels)
- manage friction & shear (e.g by positioning HOB)
- protect bony prominences
- avoid unnecessary pads/sheets/clothing
- decrease moisture
- reposition q2h
What are the risk factors for pressure injuries in older adults?
- frail, nonambulatory, and/or neurologically impaired individuals
- presence of illness and severity of it
- involuntary weight loss
- poor nutrition, dehydration, hypoproteinemia (low levels of protein in the blood), and vitamin deficiencies.
- impaired sensory perception
- impaired mobility
What is tissue tolerance? What affects tissue tolerance?
the pressure that can be endured by tissue without impairing cellular respiration or causing ischemia(highly variable between body locations and persons).
affected by: moisture friction shearing amount of pressure age
directly related to:
malnutrition
anemia
low arterial pressure
People, who have vascular peripheral deficiencies are at high risk for pressure ulcers on what part of the body?
Heels
Pressure ulcer complications include?
Wounds; infection; sepsis; needing grafting or amputation; death
What term indicates redness of skin?
Hyperemia
What nursing interventions help maintain skin integrity?
- take action to eliminate friction and irritation to the skin (such as that caused by shearing)
- reduce moisture so that tissues do not macerate (soften)
- displace body weight from prominent areas in order to facilitate circulation
- position changes, add pillows, establish a turning schedule
- monitor nutritional intake (including serum albumin, hematocrit, and hemoglobin levels)
- diet should be high in proteins, carbs, and vitamins to promote tissue growth (if pt lacks diet, can rx appetite stimulants)
- consult wound care nurse
Can a wound that is covered with necrotic tissue be staged?
NO; the necrotic tissue must be debrided or removed to expose the wound base to allow for assessment
