Prolonged pressure on bony prominences leads to compression of the skin and underlying tissues.
Common locations for pressure injuries: back of the head, ears, heels, and coccyx.
Risk Factors
Medical Conditions:
Diabetes: Leads to neuropathy, causing a lack of sensation in feet making injuries unnoticed. Also affects blood perfusion due to damage in blood vessels.
Decreased Mobility: Increased risk due to limited movement, leading to pressure accumulations.
Malnutrition: Inadequate protein intake, particularly albumin, hinders tissue healing.
Mechanical Factors
Friction: Caused during repositioning in bed or adjusting the head of the bed.
Devices contributing to friction: CPAP masks, pulse oximeters, and NG tubes can cause localized injuries through constant pressure.
Symptoms of Pressure Injuries
Redness, swelling, warmth, and pain in affected areas. Signs of infection may include increased warmth and drainage.
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.