pressure injury

pressure injury is a…

NEVER EVENT

cause

continuous pressure

tissue ischemia

• shear

• friction

what does pressure injury do…

target area of bony prominence

blood flow is compromised

tissue breakdown

• reach bony surface

stages

I → non-blanch, skin intact

II → no necrotic tissue

III → no fascia, muscle and tendon exposed

IV → fascia, bone/tendon/cartilage exposed

deep pressure injury

non-blanch

deep red, maroon, purple

intact and non-intact skin

boggy feeling

nurse consideration

turn pt every 2HR

special dressing

support surfaces

pressure injury from devices

resp mask/tubes

tubes and drains

immobilization devices

contributing factors to pressure injury

moisture

• urine

• fecal matter

• sweat

• saliva

nutrition

• low prealbumin

• high A1C

• cachexia

• anorexia

comorbidities

• diabetes

• lymphedema

• smoke

• age

• infection

impaired sensation

• spinal injury

• cognitive injury

• neuropathy