Pressure injuries/ROM/assessment - Exam 3

What are some important health history facts to know about an incoming pt?

Existing wounds/lesions, activity and mobility (walk? assisted? wheelchair? bedrest?), nutrition, pain (can interfere with mobility), incontinence

How do you want to do a skin assessment?

Systematically (head to toe)

For acute care, when do you do a skin assessment on pts?

every shift

Why is it important to know the anatomical structure of the skin?

To know how to stage pressure injuries

What is the epidermis?

Protective waterproof layer of keratin, cells have no blood vessels of their own, regenerates easily and quickly

What is the dermis?

Elastic tissue made primarily of collagen. Contains nerves, hair follicles, glands, immune cells, and blood vessels

What is the subcutaneous?

Anchors the skin layers to underlying tissues

What is the largest organ in the body?

Skin

What are factors affecting the skin?

Resistance to injury is affected by age, amount of underlying tissues, and illness. Adequately nourished and hydrated body cells are resistant to injury. Adequate circulation necessary to maintain life

How does the structure of skin change as a person ages?

The maturation of epidermal cells is prolonged, leading to thin, easily damaged skin

What are some skin developmental changes in older adults?

Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure

Who is more susceptible to skin injury?

Very thin and very obese people

What are intentional wounds?

Surgical

What are unintentional wounds?

traumatic

What is a device-related injury?

Any harm or damage to a patients body caused by a medical device used during care

When do device-related injuries happen?

When devices apply prolonged pressure, friction, or shear to the skin or underlying tissues

What is the main difference between device-related injuries and pressure injuries?

In device related injuries the cause is documented as the device (you do not STAGE)

What are some principles of would healing?

Hand hygiene, adequate blood supply, free from foreign material, proper nutrition.

What are factors affecting pressure injury development that nurses can control?

Immobility, malnutrition, fecal and urinary incontinence

What is microclimate (in terms of mechanisms in pressure injury development)?

temperature and moisture of the skin

What are main risks for pressure injury development?

Nutrition and hydration, immobility, mental status, age

What are pressure points?

Points on the body that are under more pressure and it is compression between surface and bone

How often do you turn a pt who is supine?

Q2-3 hours

How long is the max amount of time a pt can be in a chair?

Max 2 hours

When can you move a pt from the bed to a chair?

Only if there an order that pt can move

What is low fowlers?

HOB raised 15-30 degrees

What is semi fowlers?

HOB raised 30-45 degrees

What is standard fowlers?

HOB raised 45-60 degrees

What is high fowlers?

HOB raised 60-90 degrees

What are ways to prevent shearing injuries?

Silicone foam dressings, low-friction or film dressings/barrier films

What are silicone foam dressings?

The best EBP to prevent sacral and heel pressure injuries and sheering

How are pressure injuries “staged”?

From 1-4

What is a Stage 1 pressure injury?

Intact skin, localized area of non-blanchable skin.

What does non-blanchable skin mean?

Red skin that when you press down on it, it stays red

What is a Stage 2 pressure injury?

Partial-thickness loss of skin with exposed dermis. Wound bed is viable, pink/red, moist, and may present as an intact or ruptured serum-filled blister

What is a stage 3 pressure injury?

Full-thickness skin loss in which adipose (fat) is visible. Undermining or tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, or bone are not exposed or directly palpable

What is a stage 4 pressure injury?

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Undermining or tunneling often occur

What is an unstageable pressure injury?

Full-thickness skin and tissue loss in which the extent of damage is obscured by slough or eschar. Cannot be reliably staged as Stage 3 or 4

What is a deep tissue pressure injury (DTPI)?

Intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration, or a blood blister.

What can indicate suspected deep tissue injury?

Bruising

What is slough?

Dead tissue, usually cream or yellow

What is eschar?

Dry, black, hard necrotic tissue

What is necrotic tissue?

Non-viable tissue due to reduced blood supply

What is maceration?

Surrounding tissue. Excessive moisture softens the skin, turns it white and causes it to breakdown. Exudate leaked from ulcers can also be a cause

Why are the heels treated differently than sacral area?

There is little tissue on heels. Difficult to heal so prevention is crucial

What do you look for when assessing wound appearance?

Size, depth, presence of undermining, tunneling, or sinus tract

What do you look for when assessing wound drainage?

Serous, sanguineous, seroanguineous, purulent

What is serous drainage?

Water (clear/yellow)

What is sanguineous drainage?

Bloody drainage

What is serosanguineous drainage?

Mixture of serous and sanguineous drainage (pale pink and yellow)

What is purulent fluid?

Pus looking

What are skin tears?

Traumatic wound caused by mechanical forces (friction, shear, removal of adhesives)

Who is more susceptible to skin tears?

Pts with fragile skin (older pts)

What is skin tear treatment?

Stop bleeding, gentle cleaners, do not remove viable flap, non adherent dressing, silicone dressings, no dry gauze

What is wound treatment?

Prevention, nutrition, dressings (keep wound moist)

What is the Braden scale?

Six point risk assessment tool for skin breakdown and pressure injury risk

What are the different points on the Braden Scale?

Sensory perception, moisture, activity, mobility, nutrition, friction and shear

What is sensory perception on the Braden Scale?

Ability to respond meaningfully to pressure-related discomfort.

What are the classifications on sensory perception on the Braden Scale?

1) Completely limited: unresponsive to painful stimuli

2) Very limited: responds only to painful stimuli

3) Slightly limited: responds to verbal commands but cannot always communicate discomfort

4) No impairment: responds to verbal commands. Has no sensory deficit

What is moisture on the Braden Scale?

Degree skin is exposed to moisture

What are the classifications of moisture on the Braden Scale?

1) Constantly moist

2) Moist: often but not always moist

3) Occasionally moist: skin is occasionally moist, linen changed x1

4) Rarely moist

What is activity on the Braden Scale?

Degree of physical activity

What are the classifications for activity on the Braden Scale?

1) Bedfast

2) chairfast

3) walks occasionally

4) walks frequently

What is mobility on the Braden Scale?

ability to change and control body position

What are the classifications of mobility on the Braden Scale?

1) completely immobile

2) very limited: can make slight changed but unable to make frequent or significant changes independently

3) slightly limited

4) no limitations

What are the classifications of nutrition on the Braden Scale?

1) very poor: NPO, never eats a complete meal

2) probably inadequate: rarely eats a complete meal, generally only about ½ what is offered

3) adequate: eats over half of most meals or is on tube feedings or TPN

4) Excellent: eats most of every meal

What is the classification of friction and shear on the Braden Scale?

1) Problem: requires moderate to maximum assistance in moving

2) Potential problem: moves feebly or requires minimum assistance

3) No apparent problem: moves in bed and chair independently and has sufficient muscle strength to lift up completely during move

What is shear?

The result of skin being pulled in one direction, however supporting structures such as muscle and bone do not move, or move in the opposite direction

What is friction?

The result of the skin being moved one way while a surface is stationary, or moves in the opposite direction

What are local factors that impede wound healing?

Inadequate blood supply, increased skin tension, infection, foreign body

What are systemic factors that impede wound healing?

Age, obesity, smoking, malnutrition, shock, chemo/radiotherapy

What are hazards of bedrest?

Pressure injury, mental impact, severe impact on m/s system and cardiac, pulmonary, nutritional. DVT, loss of muscle mass and bone density.

What is a contracture?

A fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part