Pressure injury

pressure injuries

localized damage to the skin and/or underlying soft tissue over bony prominence or related to a medial or other device occurs from intense or prolonged pressure

common pressure areas in supine

sacrum/coccyx, heels

common pressure areas in sitting

ischial tuberosities

common pressure areas in sidelying

trochanters

stages of pressure injuries

stage 1, 2, 3, 4, unstageable, deep tissue injury

most superficial skin breakdown is associated

with moisture and/or friction rather than pressure/shear

most superficial ulcers

do not progress to deeper stages

wounds cannot be

backstaged

stage 1 pressure injury

non-blanchable erythema of intact skin, changes in sensation/temp/firmness, color changes do not include purple or maroon discoloration

stage 2 pressure injury

partial thickness loss of dermis without slough, eschar or granulation, wound bed is viable, pink/red, moist and may be an intact or ruptured serum filled blister - painful with exposed nerve endings

stage 2 pressure injuries are not used to describe

moisture associated skin damage or incontinence associated dermatitis

stage 3 pressure injury

full thickness tissue loss with slough present that doesn't obscure the tissue, adipose tissue exposed but not muscle/fascia/tendon or bone, could have undermining/tunneling

stage 4 pressure injury

full thickness tissue loss with muscle, tendon or bone exposed, slough may be present and often has undermining/tunneling

unstageable pressure injury

full thickness tissue loss in which the depth of wound cannot be determined due to slough/eschar (cant visualize wound bed)

deep tissue injury

non-blanchable deep purple, red or maroon localized area of discolored intact skin or blood-filled blister

deep tissue injuries are due to

damage of underlying soft tissue from pressure and/or shear

pathophysiology of pressure injuries

ischemia, impairment of lymphatic flow, reperfusion injury, deformation of tissue cells (unrelieved external pressure can cause ischemia and necrosis)

friction

two forces moving against eachother (moving feet back and forth against sheets)

shear force

force applied against a surface as it moves or slides in an opposite but parallel direction

tissue hyperemia (blanchable redness) timing

30 minutes to damage, 1 hour with pressure relief to recover

tissue ischemia (deeper redness with damage of underlying tissue) timing

2-6 hours of unrelieved to damage, 36 hours with pressure relief to recover

necrosis timing

>6 hours of unrelieved pressure to damage, reversal may not occur

some extrinsic factors to pressure

bed surfaces, cushions, clothing/braces, wheelchairs, foreign objects, etc.

patients at the highest risk for pressure injuries

SCI, elderly orthopedic immobility, in critical care or ICU, lack of protective sensation, edema, malnourishment, incontinence, muscle/skin atrophy

6 subscales of pressure injury risk assessment via braden scale

sensory perception, mobility, activity, moisture, nutrition, friction, shear

cut off scores for pressure injury risk assessment

>/=18 is ok, <10 is very high risk (score ranges 6-23)

skeletal/muscular structure pressure ulcer assessment

identify bony prominences at risk and assess overlying soft tissue

sensation pressure ulcer assessment

cutaneous areas lacking sensation are at highest risk for breakdown

ROM/spasticity pressure ulcer assessment

affect patient positioning, spasticity can cause shearing, contractures, position of comofort = position of deformity

other assessments to note for pressure ulcers

visual field deficits, GI status, cardiopulmonary, neurovascular, cognition

seating surfaces/cushions provide

much needed pressure redistribution

proper positioning can help prevent

muscle related deformities, pain and wound development

proper wheelchair and cushion fitting can promote

appropriate mobility and overall function

research demonstrates that a properly fitted wheelchair

enhances comfort while preventing pressure ulcers

a wheelchair cushion cannot overcome a

poorly fitted wheelchair to protect skin from breaking skin

wheelchair measurements for fitting

seat height, depth, and width, back height, footrest length, armrest height

cushion selection must reflect the

needs, function, and activities of the user

foam cushions

one or more types of foam with different tensile recoil

advantages to foam cushions

inexpensive, lightweight, comes in many stiffnesses, can be carved

disadvantages to foam cushions

heat insulator, needs to be protected from light and and moisture, short lifespan

air cushions

fingerlike projections filled with static air

advantages of air cushions

lightweight, offers adjustability, easily cleaned

disadvantages to air cushions

inflation needs to be checked regularly, can be punctured, expensive

elastomer cushsions

varying thickness of viscoelastic polymer

advantages of elastomer cushions

used as top layer to envelop buttocks and dissipate heat

disadvantages of elastomer cushions

heavy and expensive, incompressible

gel cushion advantages

displaces in response to load to envelop buttocks, some fluids provide heat transmissibility

disadvantages to gel cushion

heavy, nonadjustable

the gel should be

repositioned before each sitting event, there should be atleast 1/2 inch between deepest part of gel and foam base

ischial offloading cushions

extreme contouring and deep nonfilled wells to allow for ischial tuberosities to be suspended in air

consider limiting seating when there is a wound...

wound locations, functional mobility, co-morbidities, cognition, caregiver support, etc.

back supports

address skin protection and position

trunk supports

assist lateral trunk stability

head and neck supports

may help with swallowing and inhibiting reflex postures

ancillary devices

seat belts, lap traus

pressure relief techniques while wheelchair bound

wheelchair pushup, leaning forward, side to side - move!!

non-powered support surfaces

not using extenral sources of energy for operation, high specification foam, air or gel overlays, water filled

powered support surfaces

using external sources of energy to operate, air fluidized beds, low airloss mattresses, kinetic therapy beds

support with bed positioning in supine

cervical spine, hip/knees slightly flexed (25-30), ankles near neutral, pelvis tipped off of sacrum

protect heels in supine with

pressure relief boots or pillows under calf/knee

with supine positioning for wound care the HOB should not go

>30 degrees unless indicated for respiratory or GI needs

pillows under the heels are

not protective (knee hyperextension, pressure on heel) (use heel offloaders)

bed positioning 30 degree sidelying

minimize pressure on trochanters and bony prominences of knee, ankle and foot, support shoulder and pelvis with pillows, separate legs with pillows, keep upper arm in 25 degrees abduction with pillow

bed positioning for prone

monitor knees and dorsal feet for pressure, elevate feet on a wedge or pillow to maintain neutral spine, uncomfy for many patients, make sure breathing in unobstructed

patient repositioning should be based on

patients tissue tolerance, level of mobility, medical condition, treatment goals, support surfaces (most facilities have a turn schedule of every 2hrs for high risk patients)

functional in bed

should be promoted

E-stim wound treatment indication

stage 2, 3, or 4 that hasnt made significant improvement 30 days after standard treatment

negative pressure wound therapy indication

stage 3 or 4 that is cavernous and has been debrided, <30% necrotic tissue in wound bed

noncontact low frequency ultrasound indication

deep tissue injury

pulsed lavage with suction indication

stage 3 or 4 that is necrotic or draining, in conjunction with sharp debridement

hyperbaric oxygen therapy indications

pressure related ulcers on foot of a patient who has diabetes

ultraviolet indications

stage 2, 3, or 4 that is suspected to have bioburden

low level laser therapy indications

no evidence for pressure ulcers