NRSG 1302- Pressure Injury

etiology of pressure

-applied to the skin and underlying tissue stops adequate blood flow

-muscle and subcut tissue is more susceptible

etiology of friction

-is a force acting parallel to the skin surface

-created by repeated movement of the patient over surfaces like bed linens or chairs

-results in superficial loss of the protective layers of the epidermis

etiology of shearing

-combination of pressure and friction when adjacent surfaces slide over one another

-skin remains against the surface, while bones and muscles move

etiology of skin moisture

-excess occurs from perspiration or incontinence

-leads to maceration and breakdown of the skin

-can lead to deep tissue necrosis

stage 1 pressure injury

non-blanchable erythema of intact skin

stage 2 pressure injury

partial thickness skin loss with exposed dermis

-wound bed is viable, pink/red, and moist

stage 3 pressure injury

full thickness skin loss

-adipose tissue is visible

-granulation tissue and rolled edges are present

-may be slough or eschar

-may be undermining or tunneling

stage 4 pressure injury

full thickness skin and tissue loss

-exposed fascia, muscle, tendon, ligament, cartilage and/ or bone

-slough and eschar may be present

-rolled edges, undermining, and tunneling occur

unstageable pressure injury

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar

-if it is cleaned, it will reveal a stage 3 or 4 pressure injury

deep tissue pressure injury

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister

-results from intense and/ or prolonged pressure and shear forces at bone-to-muscle interfaces

what is the BRADEN scale?

a scale used to predict pressure sore risk

-6 areas: sensory perception, moisture, activity, mobility, nutrition, and friction & shear

-the lower the score the more at risk for developing pressure injuries

prevention of medical device related injuries:

-choose correct size

-cushion and protect skin with dressings

-inspect skin under and around device

-rotate sites of oximetry probes, O2 masks, and prongs

-reposition devices

-avoid high risk placement of devices

-educate staff

-be aware of edema under devices and skin breakdown

nursing interventions to prevent pressure injuries

-reposition patient q2h

-keep skin clean/dry

-asses patient's incontinence pads (if incontinent)

-keep linens wrinkle free

-apply lotion to dry skin

-lift patients w/ draw sheets to avoid friction

-encourage food/fluid intake

-use specialty beds & devices to help decrease pressure injuries

-treat underlying medical conditions

-provide quality education and communication