Pressure Injuries

Wounds that progress thru normal stages of healing w/in a timely fashion

2 types: Partial & Full thickness

Acute Wounds

what acute wound category can be

Superficial: extends thru epidermis & papillary dermis

Deep: extends thru epidermis & reticular dermis

Heals by “budding” from skin appendages

Does not go thru stages of healing (deroofed blisters)

partial thickness

what acute wound category can extend thru epidermis & entire dermis, reaching subQ tissues & may erode into or thru muscle, down to bone?

Heals by wound contraction, goes thru all stages of healing

Full Thickness

what are wounds that fail to heal w/in expected timeframe for underlying wound etiology?

All began as acute wounds but failed to progress thru normal sequential healing phases

Due to cellular abnormalities that develop due to prolonged inflammation

Also fail to heal due to decreased response to growth factors

chronic wounds

common characteristics of chronic wounds

Low mitogenic activity

High inflammatory citokines

High Proteases

Senescent cells

what wounds cover areas of local tissue trauma, usually developing where soft tissues are compressed by external loads?

Almost always over bony prominences (sacrum, ischia, greater trochanter, malleoli, calcaneus {95% over these 5 locations})

pressure injuries/ulcers (pressure & sheer)

what is perpendicular force or load exerted in a specific area, causing ischemia & hypoxia of tissues?

pressure

what lateral forces cause distortion of the tissue along fascial planes?

Causes undermining

shear

All possible causative factors of pressure injuries/ulcers?

magnitude & duration of pressure: High loads, short durations & low loads, long durations

Friction/shear

Temperature/moisture/Perspiration or incontinence

muscle atrophy/medications/malnutrition

what is the 1st clinical sign of pressure ulcer formation?

Red area that turns white when lightly pressed on, quickly returns to red

Blanchable erythema

what involves more severe damage & is commonly 1st stage of pressure ulceration?

non-blanchable erythema

what stage of pressure injury/Ulcer has intact skin w/ non-blanchable redness of localized area?

Pressure Injuries/Ulcers stage I

what stage of pressure injury/Ulcer has partial thickness loss of dermis, shallow, open ulcer w/ a red-pink wound bed w/o slough? may also present as an intact or open serum-filled blister

Pressure Injuries/Ulcers stage II

what stage of pressure injury/Ulcers has full-thickness tissue loss? SubQ fat may be visible; bone, tendon, muscle, not exposed

Pressure Injuries/Ulcers stage III

what stage of pressure Injury/Ulcers has full-thickness tissue loss w/ exposed bone, tendon, or muscle?

Pressure Injuries/Ulcers stage IV

what stage of pressure Injury/Ulcer has full-thickness tissue loss in which base of ulcer is covered by eschar in wound bed. Until slough/eschar is removed to expose base of wound, the true depth & stage can not be determined?

unstageable

what stage of pressure injury/ucler has purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear?

DTI

Pressure Injuries/Ulcers staging can not go backwards. The PI should always be referred to as their

highest staging level. When closed, refer as “closed (stage) ulcer”

When healing, document as “healing (stage) ulcer w/ granulation over X% of wound bed”

what pressure injury/ulcer scale is commonly used to assess risk of PU?

Assesses mobility, activity, sensation, moisture, nutrition, friction & shear

High reliability; Score range is 6-23; 18 & below at greater risk

Braden Scale