3 - Pressure Injuries (Ulcers)

what is a pressure injury?

localized area of soft tissue injury

what causes pressure injuries?

unrelieved pressure

where are pressure ulcers usually located?

over bony prominences

pressure ulcers are damaging to…

underlying tissue

What is the threshold for ischemia to occur in terms of pressure?

when external pressure exceeds capillary pressure, which is between 12-32 mmHg

What is the relationship between pressure and time to ulceration?

inverse relationship → higher pressure means ulcers will form in shorter amount of time

what are the variables that can contribute to pressure ulcers?

• Pressure

• Shear

• Moisture

• Friction

why is underlying soft tissue more susceptible to pressure than skin?

due to increased capillary density

when will Medicare reimburse for pressure sores?

if noted 2 days of admission

where is the most common site of pressure injuries?

sacrum

where is the second most common site of pressure injuries?

heels

heel pressure sores are higher risk in people with?

peripheral vascular disease, hip fracture, and neuropathy from diabetes

what should you do to avoid sacral pressure sores?

Avoid slouching in bed or chair

what patient population is at highest risk for trochanter pressure injuries?

contracted → side-lying

what patient population is at highest risk for ischium pressure injuries?

paraplegics

what would cause lateral foot pressure sores?

side lying, rotated foot

what is used to describe the extent of tissue involvement in the ulcer?

staging

what are the stages of pressure sores?

Stage I, II, III, IV and unstageable

as stages increase, ____ tissues are involved

deeper

T/F You can “down-stage” as wounds heal

FALSE

Appearance of stage 1 in lightly pigmented skin?

localized area of non-blanchable erythema

How do Stage 1 pressure injuries look in darker skin tones?

red, blue, or purple hues

is there open skin with stage 1 injuries?

no, skin remains intact

What does "non-blanchable erythema" mean?

Redness that does not turn white when pressed, indicating damage to underlying tissues.

How does a Stage 1 Pressure Injury differ from surrounding skin?

The affected area may be:

• Warmer or cooler

• Firmer or boggy (skin swollen or can feel fluid underneath)

• Painful or itchy

When should bony prominences be inspected for pressure injuries?

With each repositioning and at least once daily

Which bony prominences are at high risk for pressure injuries?

• Hips

• Sacrum

• Heel

• Coccyx

What should be done if signs of a pressure injury are found?

Treatment must start promptly, including documentation and pressure relief

How can heels be properly inspected for pressure injuries?

Use a mirror if needed to check hard-to-see areas

what is a stage II pressure injury?

partial thickness skin loss involving epidermis and/or portions of dermis

what stage is the ulcer superficial?

stage II

what does stage II look like?

Partial thickness skin loss (shallow)

Looks like an abrasion or blister

what does the surrounding skin look like in stage II?

normal

what would skin inspection look like for stage II?

Inspect skin for shallow wounds or shiny areas of skin loss

what shouldn’t you classify as a stage II injury?

skin tears, erosion from urine or feces

wounds covered with slough where deeper regions are suspected

What defines a Stage III Pressure Injury?

full-thickness skin loss (epidermis and dermis missing)→ Damage or necrosis of subcutaneous tissue

do stage III pressure injuries go through fascia?

no, it might extend down but does not go through

what stage has a deep crater with or without undermining of adjacent tissue

stage III

what does the ulcer bed look like in stage III?

may be subcutaneous fat, slough, necrosis or granulation tissue

Do not label deep wounds covered with nonviable tissue as Stage III, label them as ______

unstageable

what does evidence of an infection look like in an ulcer?

Redness, swelling, pain, warmth, exudate

what is a stage IV pressure injury?

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.)

what stage is associated with tunneling or undermining?

stage IV

Appearance of stage IV injuries? (3)

• Deep wound

• Visible or palpable bone

• May or may not have exposed tendon, slough or eschar, undermining or tunneling

why might you use a probe in Stage IV?

might have to check if bone is exposed

an ulcer is covered with necrotic tissue, what stage?

unstageable

An area of the ulcer beneath the skin surface that extends under the edge of the wound

undermining

Narrow extensions into the surrounding tissue from the sides of an ulcer

Also called sinus tracts

tunneling

a tunnel or sinus tract that ends in another structure or hollow viscous

fistula

what is an unstageable pressure ulcer?

covered with eschar or slough and the true base of the wound cannot be seen

A pressure related wound that begins in subdermal tissue

deep tissue injury → NOT STAGE 1

how does a deep tissue injury look?

Initially appears purple or blue

deep tissue injury usually leads to denuding of the_____ and _____ formation

epidermis; eschar

When should a pressure injury be staged?

At the time of initial assessment

If the ulcer deteriorates (highest stage defines the wound)

If the ulcer deteriorates, what stage defines the wound?

the highest

How should a healing pressure injury be documented?

Use the original stage with "healing" (e.g., healing Stage III)

Do NOT down-stage the ulcer as it heals

Do pressure injury stages indicate healing progression?

No, stages do NOT show how an ulcer is healing or progressing

what are the essential elements to a comprehensive pressure injury assessment?

• Site

• Stage

• Size - Depth

• Type of tissue exposed

• Surrounding skin (Periwound area)

• Tunneling, sinus tract, undermining

• Pain

• Exudate

how do you measure depth of a wound?

Use a sterile applicator to probe the depth of the wound

Tunneling and undermining will require ______ to reach these areas

dressings

what should you do if there is dead space in a wound?

fill with dressings

what happens if you don’t fill dead space with dressings?

false roof can develop

what can be included in pressure injury treatment?

• Pressure reduction

• Debridement

• Cleansing

• Treatment modalities

• Dressings

• Nutritional consult - need

• Surgical consult - need

what is an active pressure relieve mattress?

powered with or without loud

what is a reactive pressure relieve mattress?

redistribute pressure when load applied