Notes on Pressure Injuries and Their Prevention
Prevention Strategies
- Reducing Risks
- Use heel protectors or cushions to reduce hard surface contact.
- Incorporate frequent repositioning and movement for all patients, especially those at risk.
- Ensure a holistic approach, including hygiene and nutrition, as well as psychological awareness to alert patients about positional changes.
- Regular Monitoring
- Assess skin regularly for any signs of pressure injury development. Check pulses, capillary refill time, skin color, and temperature.
Complications Associated with Pressure Injuries
Infections
- Infection can occur if skin integrity is breached. Types include cellulitis and osteomyelitis (often seen with IV drug users due to repeated punctures).
- Serious systemic infection: Sepsis, characterized by fever, increased heart rate, and potential organ failure. It has a high fatality rate if untreated.
Types of Wounds
- Classification based on tissue layers involved: Stage one through four, using descriptions like slough, eschar, and granulation tissue. Tunneling and undermining are key identifiers in wound assessments.
Assessment Techniques
Wound Assessment
- Document size in centimeters, assess surrounding tissue for signs of maceration or infection, and implementation of the "Coca" method to note color, odor, consistency, and amount of drainage.
- Use a scale for risk assessment (like the Braden scale), where a score of 18 or below indicates higher risk for developing pressure injuries.
Intervention Evaluation
- If interventions fail, it may necessitate consultation with a physician for alternative strategies or treatments.
Nutritional Considerations
- Importance of Nutrition
- Adequate protein intake is crucial for wound healing. Assess albumin levels to evaluate nutritional status.
- Encourage consumption of high-protein foods and hydration as part of nutritional intervention strategies.