Wound diagnoses part 2a: Pressure

which types of patients are at risk for pressure injuries?

immobile

decreased sensory perception

decreased activity level

how would most pressure injuries develop?

related to surgery, OR table

hypotensive episodes

procedures type duration

what are pressure injury risk factors?

limited mobility or limited activity

current pressure injury

previous pressure injury

skin status changes

pain at pressure points

what are additional risk factors

perfusion and circulation deficits

oxygenation deficits

impaired nutritional status

moist skin

increased body temp

what are risk factors in neonates and children

skin maturity

perfusion and oxygenation

illness severity

duration of critical care stay

what are some causes of pressure injury

damaged caused by tissue deformation and ischemia

immobility main causative factor

what are the effects of pressure injury attributed to

intensity

duration

tissue tolerance

what is the capillary closing pressure?

12=32 mmHg

how high can pressure get in an unpadded chair

300 mmHg

what are some extrinsic fctors

friction

shear

moisture

how to prevent friction

use special linen, lift do not drag and change positions regulary

what does shearing forces do>

deep tissue damage

how to prevent shear forces?

lift pt using draw sheets or pads: DO NOT DRAG

use positioning devices when sitting to prevent sliding

what can moisture do?

weaken skin

cause pH changes

what are some intrinsic factors

skin temp

malnutrition

advancing age

decreased arteriolar pressure

emotional stress

smoking/ vaping nicotine

chronic disease or injury

what is stage 1 pressure injury

non blanchable erythema of intact skinwith localized redness over a bony prominence.

what is stage 2 pressure injury

partial thickness skin loss with exposed dermis

what is stage 3 pressure injury

full thickness skin loss, exposing subcutaneous fat. It may extend into the underlying fascia.

what is staged 4 pressure injury

full thickness skin and tissue loss

what is moisture associated skin damaged

commonly experienced with sedentary lifestyle, antibiotic use, and or obesity

skin folds, buttock area, under dressings, stoma

what is MASD caused by

prolonged exposure to urine

fecal matter

perspiration

wound exudate

effluent from ostomy

saliva

what types of MASD are there

incontinence associated dermatitis

intertriginous dermatitis

how to create intertriginous dermatitis

dry area carefully, use polyester silver cloth strips gently secured in folds

preventions of medical device induced wounds

keep skin clean and appropriately hydrated

avoid alkaline soaps and cleansers

avoid vigorously rubbing skin

protect from moisture, urine, fecal matter and wound exudate

low friction

soft silicone multi layer foam dressings over pressure points