Unit 1 - Week 3 - Wound Etiology; Pressure Injuries

Pressure injuries causes

localized area of necrosis that develops when tissue is compressed between a firm surface and bony prominence

Does pressure need to be greater than the capillary closing pressure and sustained for more than 2 hours for pressure injuries to occur?

NO, more pressure, the shorter time it takes for an injury to occur.

what factors can determine the time it takes for a pressure injury to develop?

-Amount of pressure

-Hematocrit, blood viscosity

-Body location

where on the body is most susceptible to pressure injuries?

area over bony prominences

Are pressure injuries always visisble as soon as damage occurs?

NO. Pressure injuries may not develop for days after extensive damage has already occurred.

Pressure concept

pressure = force per unit area.

Pressure dispersed over a wider area _______ pressure

reduces

Whose at risk for pressure injuries?

-Those with spinal cord injuries

-Hospitalized patients

-Individuals in long term care facilities

pressure occurs in:

-bed bound individuals

-Patients with improperly fitted cast or splints

-Patients who sit for prolonged periods

-Neonates.

general process of pressure related cell death

Pressure -> ischemia -> acidosis -> inflammation -> increased capillary permeability and edema -> local tissue anoxia -> necrosis

Major risk factors for developing pressure injuries

-Pressure-time relationship

-shear and friction

-moisture

-impaired mobility

-malnutrition

-impaired sensation

-advanced age

-history of previous pressure injury

additional risk factors for developing pressure injuries

-Ischemia reperfusion injuries

-Low diastolic BP <60 mmHg

-Peripheral vascular disease

-Elevated temperature

-Renal disease

-RA

-Altered mental state

-Diabetes

-Smoking

-Psychosocial factors

Pain level for pressure injuries

Painful unless medical condition that inhibits pain

Location of pressure injuries

Bony prominences, areas from outside pressure( CASTS and shoes)

Periwound and extrinsic tissue with pressure injuries

-surrounded ring of erythema

-localized warmth

-fibrosis and induration

-dermatitis, especially with incontinence.

Pulses with pressure injuries

-Normal unless arterial disease

greater than 80% of people with healed ulcers have

PAD

Temp with pressure injuries

-Increased in areas of reactive hyperemia (blanchable erythema)

-decreased in areas of ischemia

reactive hyperemia

blanchable erythema

Presentation of pressure ulcers

-Range from non-blanchable erythema of intact skin to full thickness destruction

-Deeper may expose the tendon, muscle, capsule, or bone

-tunneling common

-May drain profusely

-Necrotic base is normal

Pressure injury grading scale

NPUAP

Pressure injury Risk scale

Braden Scale

Pressure injury description scale

PUSH scale

stage 1 pressure injury

non-blanchable erythema of intact skin. Only epidermal damage can be noted visibly

stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both. Presents as a shallow crater without slough, eschar or bruising.

stage 3 pressure ulcer.

full thickness tissue loss with visible fat. A deep crater may have tunneling or undermining. Bone, tendon, and ligaments are NOT visible

Stage 4 pressure ulcer

Full-thickness tissue loss with exposed fat, bone, muscle, tendon, cartilage, capsule. Deep ulcer with extensive necrosis.

unstageable pressure ulcer

unstageable if the base is obscured by eschar or slough. Wound will be stage 3 or 4 once tissue is removed.

can you downgrade a pressure injury?

No. The ulcer will be labeled that stage until it is healed.

deep tissue pressure injury

-intact or non-intact skin

-persistent non-blanchable area of deep red, maroon, or purple discoloration or epidermal separation revealing a blood blister or dark wound bed.

-area may be painful, firm, mushy, boggy, or warmer or cooler than surrounding tissue.

medical device related pressure injury

pressure injury resulting from devices applied for diagnostic or therapeutic purposes. injury will conform to the shape/pattern of the device.

Mucosal membrane pressure injury

pressure injury to a mucosal membrane with current or prior history of medical device used in the same location.

Braden scale

A tool for predicting pressure ulcer risk

Braden scale categories

Mobility, activity, sensory perception, skin moisture, nutritional status, friction and shear.

Braden scale ranges of score

scores range from 1 (being the worst) to 4 (being the best)

what Braden scale score will indicate greater impairment and higher risk of pressure ulcer?

Lower scale Braden scores.

Braden scale <18

at risk

Braden scale 15-18

mild risk

Braden scale 13-14

moderate risk

Braden scale <13

high risk

Pressure Ulcer Scale for Healing (PUSH)

Categorizes ulcer with respect to surface area, exudate, and type of wound tissue; measured over time provides an indication of the improvement or deterioration in healing.

PUSH score interpretation

score from 8-24, with the higher score indicating a more severe ulcer.

PUSH healing score

PUSH initial - PUSH reassessment score.

Positive score = improvement

Education for prevention of pressure ulcers

daily skin inspections, position changes, transfer techniques, and incontinence management.

Positioning to prevent pressure ulcers.

-30 degree lateral position, not directly on the side.

-Pillows/pads between bony prominences.

-Head of bed at lowest degree.

-Bed linens free of wrinkles

Mobility for pressure ulcer prevention

-Balance pain control and sedation.

-Linens loose enough so patient can move.

-PT assists with mobility.

N

O

U

L

C

E

R

S

-Nutrition and fluid status

-Observation of skin

-Up and walking or assist with position changes

-Lift, don't drag.

-Clean skin and continence care

-Elevate heels

-Risk assessment

-Support surfaces.

S

K

I

N

-Surface selection

-Keep turning

-Incontinence management

-Nutrition

Tests for pressure ulcers

Cultures, bone scans, albumin levels/labs

Risk factors to manage for pressure ulcers

-hyperglycemia

-anemia

-malnutrition

-incontinence

Surgery for pressure ulcers

-Debridement

-Musculocutaneous flaps

Musculocutaneous flap

Surgical procedure used to close state 3 and 4 pressure injuries by rotating a muscle and overlying tissue along with the blood supply to fill the wound defect.

Pressure injuries heal

slowly

Stage 1 pressure ulcer healing time

1-3 weeks

Stage 2 pressure ulcer healing time

average 23 days

stage 3-4 pressure ulcer healing time

8-13 weeks

When should a pressure injury be reassessed for alternatives?

When the size doesn't decrease within two weeks.

PT interventions for pressure injuries

Functional mobility, pelvic floor exercises, aerobic exercise, strength training, pressure relieving devices, wound management, Biophysical agents

functional mobility for pressure ulcers

rolling, gait, pelvic floor exercises for incontinence

Why to do aerobic exercise for pressure ulcers?

Increase perfusion

why strength training for pressure ulcers?

Promote mobility

Strategies for wound management

-moisture barriers to the peri-wound.

-Dressings promoting moist wound environment, and charcoal dressings for odor.

-Debridement.

Biophysical agents

-Electrical stimulation for stage 2, 3, and 4 ulcers.

-Pulsed lavage and suction for pressure injuries with high bio-burden or infection.

-UV ultrasound, negative pressure therapy.

Local wound care goal

warm, moist, granular wound bed with healthy surrounding tissue to promote closure.

How to cleanse a pressure ulcer

warm saline or water.

necrotic tissue should be ____

debrided.

What should the tissue surrounding the pressure injury be protected from?

chapping, chafing, excessive moisture, strong adhesives.

Why must necrotic tissue be removed?

To get the full picture, because depth can be perceptive.

What wounds should you NOT debride?

Those that are dry, and eschar covered in ischemic limbs.

After 1 hr of sitting, how long does it take to repurfuse

2 Full minutes

When sitting, frequent pressure relief should occur how often?

every 10-15 minutes

When in bed, how often should you reposition?

at least every 2 hours

Stage 1 pressure injury in darker pigmented skin

Non-blanchable erythema

Erythema in dark skin tones

color may differ from the surrounding skin (purplish/bluish) and may not have visible blanching.

What should we inspect for with stage 1 pressure injuries in pigmented skin?

-Discoloration over bony prominences.

-Temperature changes.

-Tissue consistency

-Pain

What tissue takes the least amount of pressure

Muscle because it has a high metabolic demand

PEOPLE WITH SPINAL CORD INJURIES HAVE A

95% risk of obtaining a pressure ulcer

Hospitalizedf pts incidence

0.4-38%

LTACH Incidence

2-24

low serum albumin can lead to

pressure injuries

people over the age 62 have

an increased risk for pressure injuries

Most pressure injuries occur over the

sacrum, Greater trochanter, ischial tuberosity, posterior calcaneus, lateral malleolus

pressure injuries least likely to occur at

abdomen and thighs

key to treating pressure injuries

PREVENTION