Pressure Injuries

Pressure Injuries Overview

Introduction

  • Textbook Reference: Burton Smith, Fundamentals of Nursing Care: Concepts, Connections & Skills, Fourth Edition.

  • Section Focus: This section covers pressure injuries exclusively.

  • Source: National Pressure Injury Advisory Panel (NPIAP) ©2020, NPIAP.com.

Risk Factors for Pressure Injuries

  • Older Age: Increased susceptibility due to skin changes and reduced resilience.

  • Emaciated: Insufficient body fat may reduce cushioning over bony prominences.

  • Incontinence: Compromises skin integrity due to moisture and friction.

  • Immobility: Inability to change positions can lead to prolonged pressure on specific areas.

  • Impaired Circulation: Reduced blood flow may impair tissue oxygenation and healing.

Staging of Pressure Injuries

  • Pressure injuries are staged based on the extent and depth of tissue damage. The classification is as follows:

Stage 1

  • Definition: Erythema of intact skin that does not blanch on pressure.

  • Care Instructions: Avoid massaging directly over the area to prevent further damage.

Stage 2

  • Definition: Partial thickness tissue loss of skin layers with exposed dermis, which may include blisters (either open or intact).

  • Risk: Higher likelihood for microorganism entry if the area is opened; harder to heal than Stage 1.

Stage 3

  • Definition: Full-thickness tissue loss involving all skin layers (epidermis, dermis, and subcutaneous tissue) but does not yet involve muscle or bone.

  • Characteristics: Possible presence of undermining or tunneling; increased risk of infection.

Stage 4

  • Definition: Full-thickness skin and tissue loss with involvement of muscle, tendon, joint, or bone.

  • Characteristics: Undermining and tunneling may be present, and there is a severe risk of infection that can lead to osteomyelitis. Healing is slow.

Unstageable Injury

  • Definition: Full-thickness tissue loss where the extent of damage is unclear due to presence of eschar (necrotic tissue).

  • Note: Eschar should not be removed; it is critical to stabilize the area before further assessment.

Deep Tissue Pressure Injury (DTPI)

  • Definition: Intact or non-intact skin that appears red, maroon, or purple in color which does not blanch.

  • Characteristics: There may be blister formation; careful monitoring is required.

  • Medical Device-Related Pressure Injury: This type of injury may display a shape or pattern consistent with the device used (e.g., splints, braces, oxygen devices).

Prevention of Pressure Injuries

  • Braden Scale: A tool to assess the risk of pressure ulcer development based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

  • Skin Assessment: Regular inspection and assessment of skin integrity are crucial.

  • Repositioning: Changing the position of patients every 2 hours to alleviate pressure on vulnerable areas.

  • Skin Care Routine: Keeping the skin clean, dry, and intact; moisturization may be necessary to prevent dryness.

  • Linens: Maintaining clean, dry, and wrinkle-free linens to provide a smooth surface that minimizes friction.

  • Fluid and Nutrition: Ensuring adequate hydration and nutrition promotes overall skin health.

  • Use of Specialty Beds and Devices: Employing equipment designed to distribute pressure evenly (refer to Chapter 16 for more details).