Hospital-Acquired Pressure Injuries Flashcards

Hospital-Acquired Pressure Injuries (HAPIs)

Basics of HAPIs

• Hospital-Acquired Pressure Injuries (HAPIs) are also known as:
  • Bedsores
  • Decubitus ulcers
  • Pressure ulcers
  • Pressure sores
• Cause: Occur at the point of contact between soft tissue and a hard surface (e.g., bony prominence).
• Clinical Presentation: Typically an inverted cone-shaped wound, with the largest area of breakdown proximal to the bone.
• Common Locations:
  • Sacrum
  • Ischial tuberosity (especially when sitting upright)
  • Lateral malleolus
  • Trochanter
  • Calcaneus
• Prevalence: Relatively low, but more likely in patients unable to ambulate regularly; even pediatric patients are susceptible.

Prevention

• Regularly examine the patient's skin color and condition.
• Change the patient's position at least every two hours.
• Elevate an immobile patient's heels off the bed.
• Limit patient positioning on the trochanter.
• Use a trapeze or draw sheet to move the patient.
• Utilize pressure-reducing or alternating-pressure devices.
• Wash and dry the patient promptly.
• Minimize friction and shearing forces on the patient's skin.
• Minimize exposure to moisture.
• Ensure adequate diet and hydration.
• Provide proper patient education regarding their condition and self-care.
• Braden scale for predicting risk of pressure-induced injury includes:
  • Sensory
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction & shear

Pathophysiology

• HAPIs begin when tissue is subjected to external pressure that the patient's cardiovascular system cannot overcome.
• Hypoperfusion: Occurs due to the pressure.
• Tissue Ischemia: Develops as a result of hypoperfusion.
• Tissue Necrosis: Occurs if pressure is not relieved and normal perfusion isn't restored, leading to HAPI development.
• Analogy: Similar to a water hose left on grass for weeks, causing dead grass underneath.
• Key Point: Impaired perfusion is the primary cause and a primary factor in delayed healing.

Risk Factors

• Decreased or impaired mobility
• Cognitive decline
• Decreased sensory perception
• Fecal or urinary incontinence
• Integumentary breakdown (excessively moist or dry skin)
• Decreased mental status
• Poor nutrition
• Friction and shear interrupting skin integrity or perfusion
• Tissue ischemia and lack of perfusion
• Tissue ischemia can occur in as little as 30 minutes, but may take as long as 240 minutes (4 hours), depending on the patient's acuity.

Classification of Pressure Injuries by Stage

• Stage I: Non-blanching erythema of intact skin.
• Stage II: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and may present as an abrasion, blister, or shallow crater.
• Stage III: Full-thickness skin loss with damage and/or necrosis of subcutaneous tissue. Wound boundaries extend further but do not penetrate underlying fascia. Bacterial infection is common, and fluid may seep from the wound.
• Stage IV: Full-thickness skin loss with extensive destruction and necrosis of overlying structures, including muscles, bones, and/or tendons. Sinus tracts (tunneling wounds) may be present, representing an abnormal passage from a pus-filled cavity to the skin surface. Necrotic tissue is present, usually with widespread infection.

Wound Care Basics

• Wound Debridement Techniques:
  • Surgical debridement
  • Hydrotherapy or irrigation
  • Larval therapy or biosurgery (use of maggots)
  • Topical enzymatic debridement
• Regular Wound Cleansing and Irrigation:
  • Used to manage delayed closure surgical wounds healing by secondary intention (left to heal from inside out with wet-to-dry dressings) and chronic wounds like pressure ulcers.
  • Clean technique (medical asepsis) is most commonly used.
• Wound Healing: Depends on controlling bacterial balance while maintaining the viability of healing tissues.

Wound Closure Methods

• Primary Closure: Direct apposition of skin edges of acute surgical or traumatic wounds after preparation, using sutures and/or staples.
• Delayed Primary Closure: Skin edges are brought together after an interval of wound management. The wound is left open initially, then closed with sutures/staples. Accepted for abdominal, chest, and surgical wounds without infection. Chronic wounds should not be closed primarily; delayed closure or coverage is preferred.
• Healing by Secondary Intention: Wound is left open and fills with granulation tissue and epithelization over time. Skin edges are not brought together. Negative pressure wound therapy may assist this process.

Wound Irrigation

• Purpose: Promotes healing by removing debris and pus, reducing surface bacteria, and loosening adherent devitalized tissue.
• Commonly Used Methods: Bulb syringes.
• Solutions: Sterile 0.9% sodium chloride and sterile water. The provider determines the appropriate solution based on resources, formulary, evidence-based practices, and hospital policies.

Pressurized Irrigation

• Too much pressure can damage tissue and increase infection risk.
• Pressure is often more important than the solution.
• Low pressure irrigation reduces Staphylococcus aureus Colony Forming Unit (CFU) count; high pressure is effective at flushing particulate matter.
• Low Pressure: 1-2 pounds per square inch (PSI).
• High Pressure: Greater than 8 PSI (>8PSI).
• Good Practice: 7 PSI or greater for wounds with obvious debris, 0.5 PSI for wounds without obvious debris.
• A 35-50mL syringe with an 18-gauge catheter can generate 7 PSI. A minimum of 250mL of solution should be used.

Inpatient Wound Care Procedure

Assessment

• Perform hand hygiene before patient contact.
• Verify the correct patient using two identifiers.
• Assess for allergies to antiseptics, medications, adhesives, packing materials (especially Iodoform), and dressing materials.
• Check provider's orders for topical wound care and irrigation, including the type of irrigation solution prescribed.
• Review the patient's last documented wound assessment for comparison.
• Assess the patient's comfort level using an organization-approved pain scale and identify symptoms of anxiety.
• Administer pain medication before procedure, if applicable.
• Reassess the patient's pain status, allowing sufficient onset of action per medication, route, and the patient's condition.

Procedure

• Perform hand hygiene and don gloves. Don gown, face mask, and eye protection if risk of splashing exists.
• Verify the correct patient using two identifiers.
• Determine the amount of irrigation solution and types of primary and secondary dressings needed and gather the necessary supplies.
• Explain the wound irrigation procedure to the patient.
• Provide the patient with privacy by closing the door or drawing the bed curtains if the room is shared.

Wound Examination and Documentation

• Examine the dressing for quality (color, consistency) and quantity (saturated, slightly moist, or no drainage) of drainage.
• Discard dressing in a waterproof biohazard bag, remove gloves, and perform hand hygiene. Don clean gloves.
• Perform a wound assessment, noting:
  • Anatomical location of the wound
  • Type of tissue in the wound by color (red, yellow, or black)
  • Approximate percentage of each tissue type in the wound bed
  • Presence of signs or symptoms of infection
  • Wound dimensions (width, length, and depth) in centimeters
  • Presence of tunneling or undermining
  • Drainage (quantity, color, and consistency)
  • Periwound (skin color, texture, and temperature)
• Place an underpad/chux beneath the area to be irrigated and place a basin to catch drainage.
• Fill an irrigation syringe with solution. Hold the syringe approximately one inch from the wound and use continuous pressure to flush the wound until at least 250mL of solution has been used. If the draining solution is not clear, continue irrigating.
• Dry the wound edges with sterile gauze.

Medication and Dressing Application

• Verify any medication using three checks and six rights.
• Apply wet-dry or dry dressing as indicated.
• Label the dressing with date, time, and Corpsman's initials.
• Remove gloves and perform hand hygiene.

Documentation

• Wound assessment before and after irrigation
• Amount and color of drainage on the dressing removed
• Amount and type of irrigation solution used
• Irrigation device used
• Patient's tolerance of the procedure
• Type of dressing applied after irrigation
• Date and time of dressing change per the organization's practice
• Pain level and response to pain medications, if administered
• Patient and family education
• Unexpected outcomes and nursing interventions

Expected Outcomes

• The patient states or demonstrates an acceptable level of comfort.
• The wound demonstrates signs of healing.
• Amount of wound drainage and tissue inflammation decreases.
• Surrounding skin integrity is maintained.

Unexpected Outcomes

• Bleeding
• Increased pain or discomfort
• Increased wound dimensions