pressure Injuries

Pressure Injuries Study Notes

Overview of Pressure Injuries

  • Pressure Injuries: Previously known as decubitus ulcers, bed sores, or pressure ulcers.

  • Misconception: It was thought that only bedridden individuals could develop pressure injuries.

  • Definition: Pressure injuries are areas of localized tissue damage occurring to the skin and/or underlying soft tissue, typically over a bony prominence or due to medical devices.

    • Caused by compression of soft tissue, leading to decreased blood flow.

    • If unrelieved, this compression results in ischemia and tissue death.

Skin Anatomy and Functions

  • Skin: The body's largest organ, integral for:

    • Sensation: Recognition of pain, touch, pressure, and temperature.

    • Thermoregulation: Regulating body temperature.

    • Metabolism & Immunity: Role in metabolic processes and immune response.

    • Fluid Balance: Helps regulate fluid levels in the body.

  • Layers of Skin:

    • Epidermis: Outer layer with no blood vessels.

    • Dermis: Beneath the epidermis; contains collagen (70% of the dermis) that is essential for wound healing, blood vessels, and nerves.

Common Skin Problems

  • List of Common Problems:

    • Dry Skin

    • Acne

    • Hirsutism

    • Skin rashes

    • Contact dermatitis

    • Abrasions

Pathophysiology of Pressure Injuries

  • Ischemia: Initial signs include

    • Redness & warmth in light skin.

    • Purple & warm in dark skin.

  • Risk Factors: Include but are not limited to:

    • Impaired sensory perception

    • Impaired mobility

    • Altered consciousness

    • Shearing forces, friction, moisture, nutrition, and age.

Pressure Injury Risk Factors

  • Comprehensive List:

    • Impaired sensory perception

    • Impaired mobility

    • Altered consciousness

    • Moisture from incontinence

    • Poor nutrition, dehydration, anemia

    • Comorbid conditions like diabetes and circulatory issues

    • Existing pressure injuries or a history of such injuries

Classification of Pressure Injuries

  • 4 Stages of Pressure Injuries:

    • Stage 1: Non-blanchable erythema, intact skin but visibly inflamed.

    • Stage 2: Partial thickness loss involving the epidermis and possibly the dermis; appears as an abrasion or blister.

    • Stage 3: Full thickness loss involving subcutaneous tissue, with possible necrosis in deeper tissue but no involvement of muscle, tendon, or bone.

    • Stage 4: Extensive damage to muscle, bone, or supporting structures (e.g., joints).

    • Unstageable: Full thickness loss where the base is completely obscured by slough or eschar.

Treatment and Management

  • Stage 1 Treatment: Keep pressure off the affected area; evaluate if it does not heal in a few days.

  • Stage 2-3 Treatment: Consult healthcare provider for further management.

Factors Influencing Wound Healing

  • Box 39.2: Key factors include:

    • Adequate blood perfusion and oxygenation

    • Nutrition and hydration

    • Management of moisture and pressure

    • Infection control

    • Age and presence of chronic conditions.

Prevention Strategies for Pressure Injuries

  • Conduct comprehensive skin assessments.

  • Monitor and maintain clean, dry skin; avoid friction and shear injuries.

  • Regularly inspect bony prominences and reposition patients every 1-2 hours.

  • Implement nutritional guidelines to support skin integrity (high protein).

  • Use specialized support surfaces based on risk level.

Braden Scale for Skin Assessment

  • Overview: A validated tool predicting pressure injury risk based on 6 subscales:

    1. Sensory perception

    2. Moisture

    3. Activity

    4. Mobility

    5. Nutrition

    6. Friction and shear.

  • Risk Level Interpretation:

    • 15-18: At risk

    • 10-12: High risk

    • Less than 9: Very high risk.

Principles for Pressure Injury Prevention

  • Factors contributing to pressure injury development can be both intrinsic and extrinsic.

  • Support Surfaces: Used to redistribute pressure over larger areas and are classified into preventive or therapeutic types.

  • Avoid placing high-risk patients on standard surfaces; utilize specialized beds and support systems instead.

Patient-Centered Care in Pressure Management

  • Tailor support surfaces to each patient's specific needs, considering their cultural background and preferences.

  • Educate patients and families about the importance of pressure injury prevention strategies.

Practical Skills in Nursing for Pressure Injuries

  • Skill 13-1: Placing a Patient on a Support Surface

    • Delegation protocols for UCPs require them to regularly monitor patient skin condition and reposition patients.

  • Documentation: Record type of support surfaces used, patient tolerance to procedures, and any changes in skin condition in the patient's chart.

Special Considerations for Diverse Populations

  • Adjust strategies based on age (children and elderly), patient mobility conditions (e.g., obesity), and unique needs of patients (e.g., those with neurological deficits).

Conclusion

  • Prevention is essential in managing pressure injuries, supported by thorough assessments, patient education, and appropriate interventions based on risk assessment tools such as the Braden Scale.