Wound Care - Pressure Injuries

pressure injuries

leads to longer hospital stays; increases risk of infection to wound; medicare/medicaid have stopped covering the cost for

how many stages of pressure injuries

four

occur when sufficient pressure on skin causes the blood vessels in an area to collapse

pressure injury

mechanical factors leading to pressure injuries

shearing force; friction

shearing force

tissue layers of skin slide on each other, causing subcutaneous blood vessels to kink or stretch

friction

rubbing of skin against another surface producing friction – may remove layers of skin

risk factors for pressure injuries

chronically ill; debilitated; elderly; incontinence; spinal cord injuries; circulatory impairment; poor nutrition

stage 1 pressure injury

localized area of skin, typically over bony prominences, that is intact with non-blanchable redness; may be painful, firm, soft, warm or cool; difficult to detect in patients with darker skin tones

stage 2 pressure injury

partial thickness loss of dermis may manifest as intact or open serum filled blisters

stage 3 pressure injury

full thickness tissue loss – subcutaneous fat is sometimes visible – no bone tendon or muscle is showing; may have slough or eschar in part of wound; tunnelling and undermining maybe present

stage 4 pressure injury

full thickness tissue loss with exposed bone, tendon, cartilage or muscle; slough or eschar might be present but cannot cover entire wound bed; increases risk for osteomylitis

unstageable/unclassified

has full thickness tissue loss – wound bed is covered by slough or eschar; unable to get true depth or stage

suspected deep tissue injury

appears as a localized purple or maroon area of discolored intact skin or a blood-filled blister; can be painful, firm, mushy, boggy, warm or cool to touch; some wounds evolve rapidly

nursing interventions

thorough skin assessments routinely; frequent position changes to prevent skin breakdown; assessment of wound including measurements, any undermining, tunnelling, amount and color of exudate, any pain or odor, appearance of exposed tissue