pressure injury

pressure injury

localized damage to skin and underlying soft tissue usually over a bony prominence or related to medical of other device

intact skin or an open ulcer

pressure injury can present as ___

intense, prolonged; shear

pressure injury occurs due to ___ and/or ___ pressure or pressure in combo w/ ___

National Pressure Ulcer Advisory Panel (NPUAP)

authoritative voice on pressure injury prevention and treat in US

pressure injury

term that better reflects the etiology of wound (old terms: bed/pressure sores; decubitus ulcers)

critical care, SC injury, acute pediatric, CV, neonatal pts

pressure injury incidence: 2x as likely in ___ units; increased likelihood w/ (4)

11 billion; 1200, 70,000

pressure injury cost: $___ in hospital costs in 2006; avg $___/day in hospital costs; management of a single full thickness pressure ulcer = $___

mechanical, ischemia

pressure injury formation results from ___ injury to skin causing subsequent ___ to underlying structures

ischemia, impaired lymphatic flow, reperfusion, tissue deformation

4 proposed underlying mechanism of pressure injury

ischemia

due to capillary occlusion

impaired lymphatic flow

causes an increased accumulation of metabolic waste products in area

reperfusion

due to inflam response that ensues after return of blood flow to ischemic area

local hyperemia, ischemia, necrosis, ulceration

4 stages of pressure wound formation

local hyperemia

clinical presentation: observed w/in 30 min of consistent pressure

local hyperemia

increase in blood flow

local hyperemia

clinical presentation: redness to area up to 1hr after pressure relieved

ischemia

clinical presentation: 2-6hrs of continuous pressure

ischemia

clinical presentation: erythema presents as deeper red color

necrosis

clinical presentation: 6hrs after continuous pressure

necrosis

clinical presentation: skin color vary from greyish to blueish w/ induration/hardness noted w/in tissue

ulceration

clinical presentation: 2 wks after necrosis has been observed

staged wounds

only type of wounds caused by pressure

1

pressure injury stage: non-blanchable erythema of intact skin

1

pressure injury stage: accounts for up to 47% of pressure injuries in geriatric pop

2

pressure injury stage: partial-thickness loss w/ exposed dermis

2

pressure injury stage: usually present as open wound that is shallow/pinkish

2

pressure injury stage: no evidence of necrotic tissue (slough or eschar)

3

pressure injury stage: full thickness skin loss

3

pressure injury stage: bone/t/m not exposed

3

pressure injury stage: evidence of necrotic tissue automatically characterizes wound at this stage

3

pressure injury stage: subcutaneous fat may be present but doesn’t obscure ability to detect depth of tissue loss

3

pressure injury stage: may include tunneling/undermining

4

pressure injury stage: full thickness skin and tissue loss

4

pressure injury stage: exposed fascia/bone/t/m

4

pressure injury stage: often see undermining and/or tunneling as well as slough/eschar present that again doesn’t obscure assessment of the wound depth

unstageable

pressure injury stage: obscured full-thickness skin/tissue loss

unstageable

pressure injury stage: base of wound covered w/ slough or eschar

unstageable

pressure injury stage: until wound is debrided, full depth can’t be ascertained

suspected deep tissue injury

persistent non-blanchable deep red/maroon/purple skin discoloration or a blood-filled blister due to damage to underlying soft tissue

suspected deep tissue injury

tissue may be boggy or mushy to palpation

medical device pressure injury

due to devices for dx or therapeutic purposes

medical device pressure injury

resultant pressure injury generally conforms to pattern/shape of device

mucosal mem pressure injury

found on mucous mems w/ a hx of a medical device in use at injury location

mucosal mem pressure injury

due to anatomy of tissue, these ulcers can’t be staged

immobility, inactivity, sensory loss, shear/friction Fs

risk factors for pressure injuries (5)

shear

Fs parallel to surface causing ischemia and jumpstarts the wound process

friction

another surface making contact w/ skin

Braden and Norton scales

2 risk assessment tools for pressure injuries

braden scale

subscales consist of sensory perception, moisture, activity, mobility, nutrition, friction/shear

higher risk

lower braden score =

lower risk

higher braden score =

norton scale

subscale consist of physical condition, mental state, activity, mobility, incontinence

17-20/20

norton scale score: low risk

PRAFO, wt-shift/reposition

interventions for pressure relief

roho cushion, air mattress, pressure mapping systems

intervention for pressure redistribution

prevent maceration, barrier creams

intervention: care for moisture prone areas

decreasing pressure on bony prominences

most critical intervention in pressure injury prevention/treat is ___ and other high risk areas

draw sheets

reduce friction/shear Fs during repositioning w/ ___ and other lifting devices

1

pressure injury stage

2

pressure injury stage

3

pressure injury stage

4

pressure injury stage

unstageable

pressure injury stage