Pressure Injuries: Causes and Prevention (LPN)

Pressure Injuries

• Pressure injuries are lesions caused by prolonged pressure against the skin, often referred to as bedsores, decubitus ulcers, or pressure ulcers.
• Tissue anoxia results after minutes to hours of unrelieved pressure on the skin.
• Spending long periods in one position causes compression of capillaries against a bed or chair, especially over bony prominences, which is a primary cause.
• Other causes include pressure from tight splints/casts, traction, or other devices.
• Immobility, decreased circulation, or neurological/sensory function impairment increase risk for pressure injuries.
• Mechanical forces including pressure, friction, and shear cause pressure injuries.
• Capillaries close at pressure levels of 25 to 32 mm Hg in otherwise healthy individuals.
• Blood supply to tissues decreases when applied pressure exceeds capillary bed pressure, impairing cellular metabolism with ischemia occurring.
• Reduced blood flow from exceeding capillary pressure causes blanching of the skin.
• The amount of time pressure is applied is directly correlated with the risk of skin breakdown and the development of pressure injuries.
• Friction occurs when the skin surface rubs over a stationary surface.
• Shearing occurs when a patient slides down in bed with the head raised, or when being pulled without being lifted off the sheets.
• Fat, muscle, and bone shift during movement with shearing, while skin and subcutaneous tissue remain stationary, causing damage deep within the tissues.
• Older patients have more risk of pressure injuries, as aging causes changes in the skin.
• Thin patients have greater risk due to less padding where pressure is present.
• Obesity is a contributing factor because adipose tissue is vulnerable to ischemic changes due to adipose tissue being poorly vascularized.
• Impaired peripheral circulation increases susceptibility to ischemic damage.

Prevention

• Use a validated assessment tool to monitor a patient’s physical condition, mental status, activity, mobility, incontinence, and risk for pressure injuries.
• The Braden Scale for Predicting Pressure Sore Risk is an example of an assessment tool that monitors physical condition, mental status, activity, mobility, and incontinence.
• Advanced age, low diastolic blood pressure, elevated body temperature, and inadequate protein intake are risk factors for pressure injuries.
• Pressure injury is classified as a Serious Reportable Event by the National Quality Forum.
• Medicare and many private insurers will not pay for treatment of stage 3, stage 4, or unstageable ulcers acquired after healthcare facility admission.
• Essential steps include careful skin examination with photo documentation upon admission and vigilance in care to prevent new injuries or worsening of existing ones.
• Cleanse skin daily with tepid water and mild soap to avoid drying it.
• Reduce friction by patting skin dry rather than rubbing.
• Lubricate skin with moisturizers after bathing to prevent dryness.
• Thoroughly dry skin-to-skin surfaces to prevent moisture exposure.
• Clean incontinent patients promptly with tepid water and mild soap, pat dry, and apply a moisture barrier to prevent skin breakdown.
• Avoid massaging bony prominences or reddened skin areas, as it can further damage ischemic blood vessels.
• Prevent damage to capillary beds by advising nursing personnel and family members to avoid massaging reddened areas, and to stop use of donut-shaped pillows.
• Develop mobility programs specific for each patient to maintain the highest possible level of mobility.
• Teach patients to shift weight every 15 minutes, if you are able, when sitting or lying.
• Provide active/passive range-of-motion exercises and turn the patient according to a written schedule; if on bedrest, turn and reposition every 2 hours because ischemia can begin rapidly.
• When positioning patients on their side, place them at a 30-degree angle/less, and not directly on the trochanter, because this area is sensitive to pressure and break down.
• Reposition patients seated in chairs every hour.
• Head of the bed should not be elevated more than 30 degrees to reduce pressure on the coccyx and sliding damage.
• Use a sheet to lift/move patients, or a bed trapeze to help move themselves.
• Elevate patient’s heels off the bed with pillows or heel elevators, making sure pillows do not apply pressure to calves.
• Protect bony prominences such as the elbows, sacrum, scapulae, ears, and occipital area.

Braden Scale

• Sensory Perception: Ability to respond meaningfully to pressure-related discomfort
• Moisture: Degree to which skin is exposed to moisture
• Activity: Degree of physical activity
• Mobility: Ability to change and control body position
• Nutrition: Usual food intake pattern
• Friction and Shear

Risk Levels

• At Risk (15-18): implement frequent turning, maximal remobilization, heel protection, and management of moisture, nutrition, friction, and shear. Apply a pressure-reduction support surface for bed- or chair-bound patients.
• Moderate Risk (13–14): implement a turning schedule; use foam wedges for 30° lateral positioning; apply a pressure-reduction support surface; maximal remobilization; heel protection; and management of moisture, nutrition, friction, and shear.
• High Risk (10-12): increase the frequency of turning, supplement with small shifts, apply a pressure-reduction support surface, use foam wedges for 30° lateral positioning, perform maximal remobilization, protect heels, and manage moisture, nutrition, and friction and shear.
• Very High Risk (9 or Below): implement all of the above, and use a pressure-relieving surface if the patient has intractable pain or severe pain exacerbated by turning, or if there are additional risk factors.
• General Care: Do not massage reddened bony prominences or use donut-type devices; maintain good hydration and avoid drying of the skin.

Prevention of Ischemia

• Avoid donut-shaped cushions because they create a circle of pressure that cuts off circulation and promotes ischemia.
• Pad skin contact surfaces, especially between bony prominences (example: place a pillow between the knees in a side-lying position).
• Use pressure-redistributing mattresses and cushions to provide redistribution of pressure for immobile patients.
• Prevent malnutrition/dehydration by ensuring adequate protein, calories, and fluid intake. Provide 2,500 mL of fluid daily unless contraindicated.
• For older adults, avoid soap/water on dry skin areas; use a moisture barrier cream or ointment before bathing to protect against water's drying effects.
• Regularly wash and thoroughly dry between toes.
• Create a bowel program, and toilet the patient often, to prevent Incontinence.
• Use perineal cleansing products to remove urine and feces residue from the perineum and anal area to prevent skin irritation.
• Use moisturizing/non-alcohol/non-perfume creams to prevent skin irritation.
• Avoid pressure over bony areas, and assist the older adults to change positions on a regular schedule.
• Remind patients to change position/shift weight while sitting in chairs to avoid prolonged pressure.
• Examine skin for red areas that indicate positioning schedule should be more frequent.
• Use pillows and pads to help maintain alignment with position changes, specialized mattresses/chair cushions to decrease pressure, and pillows under the calves to keep heels off the bed.
• Encourage older adults to be out of bed and active throughout the day.
• Provide a high-protein, vitamin-rich diet, and monitor/encourage fluids unless contraindicated.
• Ensure bed linens are kept dry and unwrinkled.

Signs and Symptoms

• Developing pressure injuries typically start as reddened areas over bony prominences that do not blanch with pressure.
• Capillary refill is checked by pressing on a fingertip: if the redness returns within 3 seconds, capillary refill is adequate, otherwise, it is inadequate.
• A pressure injury that stays red and does not blanch should raise concern.
• Progression to an open, ulcerated area occurs if pressure is unrelieved with lack of healing.
• In dark-skinned patients, observe for skin color changes rather than blanching.
• The most common sites for pressure injuries are the sacrum, heels, elbows, lateral malleoli, greater trochanters, ischial tuberosities, base of the skull, scapulae, and ears.
• Most patients experience pain, requiring continual monitoring, documentation, and treatment.

Color Classification

• Black wounds indicate tissue necrosis.
• Yellow wounds have slough, which is a layer of dead tissue that is usually yellow, creamy, or tan and may be infected.
• Red wounds are pink or red and are in the healing stage.
• Wounds can contain a mixture of black, colors. Necrotic (black) wounds are a sign of dead tissue. Beefy red wounds that are healing are desired. Treat the worst color present in the wound first.

Complications

• Wound infection is a common complication.
• Other complications can include new injuries appearing, or injuries progressing to a deeper state.
• Some wounds may take more time to heal or have chances of not fully healing.

Diagnostic Tests

• Open pressure injuries are colonized with bacteria but adequate cleansing and debridement typically prevent it from progressing to clinical infection.
• Culture and sensitivity tests may identify causative organisms in suspected infection sites but results need to be interpreted with secondary intentions.
• Bacterial growth may exceed local tissue defenses when the wound is extensive, and will ultimately result in a true wound infection.
• Noninvasive arterial blood supply studies are recommended for suspected non-healing/ischemic wounds.
• Biopsies of large, extensive unhealing wounds can help ensure cancer isn't present.

Therapeutic Measures

• Treatment for pressure injuries varies according to the size, depth, and stage of the pressure injury; the special needs of the patient; and health-care provider (HCP) preference.
• Pressure must be relieved from affected areas. Cleanliness must be maintained.
• Treatment includes debridement, cleansing, and dressing of the wound to provide a moist and healing environment.
• Debridement is the removal of dead or nonviable tissue from a wound to help facilitate granulation. May be done with or without surgery.
• Nonsurgical debridement includes mechanical, enzymatic, and autolytic methods. Surgical debridement used in patients who have sepsis/cellulitis or to remove extensive eschar.
• Eschar is a black hard scab/thick tissue that forms from necrotic tissue and hides the true depth of the wound to heal

Mechanical Debridement

• Scissors and forceps can selectively remove nonviable tissue.
• Dextranomer beads can be sprinkled over the wound to absorb exudate and products of tissue breakdown as well as surface bacteria.
• Wet to dry gauze: wet gauze directly on wound/allow to dry completely, avoiding surrounding healthy tissue. The dying process causes the adhere to the wound which results in nonselective debridement when removed (painful/patient should be premedicated).

Enzymatic Debridement

• Enzymatic debridement involves application of a topical enzyme debriding agent.
• Most debriding agents are proteolytic enzymes to digest necrotic tissue and only be applied to the wound, and avoid contact with healthy tissue.

Autolytic Debridement

• Autolytic debridement uses a synthetic/moisture-retentive dressing over the injury.
• Eschar self-digests due to enzymes in the wound’s fluid environment.
• Autolytic debridement shouldn't be used for infected wounds since the infection would worsen.

Surgical Debridement

• Surgical debridement removes devitalized tissue, eschar from a scalpel, scissors, or other sharp instrument.
• Surgical debridement may be performed in an operating room, a treatment room, or the patient's room.
• Following surgical debridement, the wound might require grafting if it is a full-thickness injury or for cosmetic purposes.

Wound Cleansing

• Injuries should undergo thorough cleansing using handheld showerheads/irrigating systems at 4–15 pounds per square inch (psi).
• A 30 mL syringe with an 18-gauge needle removes bacteria.
• For red wounds, utilize a needleless 30 to 60 mL syringe to gently prevent trauma and bleeding.
• 250mL normal saline(sometimes tap water) if using the irrigation system.

Wound Dressing

• Wounds can heal rapidly with minimal bacterial colonization and minimal colonization about 98.6°F. It’s ideal if the dressing is left on for as long as possible. Also, the epidermis must stay moist for healing to occur.
• Dressings must vary in size, location,depth, stage of injury and preference. Common dressing materials for pressure injuries hydrogel dressings, biological dressings, and cotton gauze.
• Hypoallergenic dressings should be used if necessary for dressings. Additionally skin protectants are used for unaffected tissue.
• No treatment will be effective if pressure continues to damage the tissue.
• LPN/LVN will provide care for client drainage device (e.g., chest tube, wound drain).

Negative Pressure Wound Therapy (NPWT)

• NPWT can heal large open-pressure injuries effectively.
• A wound is packed loosely with a sterile sponge and covered with an occlusive dressing in NPWT. Vacuum source used in order to remove excess drainage and infectious material with circulation speeding healing time.
• NPWT also maintains optimal moist environment (evidence supports effectiveness for diabetic pressure injuries.) NPWT is effective for other deep injuries.
• Risks can range from bleeding in patients of risks.

Evidence Based Practice

• The National Pressure Injury Advisory Panel did research with 14 wound organizations from countries. Best practices include checking perfusion stats of heels when collecting data, elevatings pressure injury with device or pillow to avoid injury on 1/2 injuries ,specially designed device or heel injury.

Nursing Process for the Patient With Pressure Injury

• Collaborate with the RN to evaluate status of the pressure injury with causes.
• Monitor risk factors such as immobility, nutrition and hydration.
• Measure wounds in centimeters with a disposable guide to determine tissue destruction.

Pressure Injury Stages

• Stage 1: The skin is still intact, but the area is red and does not blanch when pressed. Warmth, hardness, and discoloration of the skin may be present.
• Stage 2: Partial-thickness skin loss with the exposed dermis. The wound bed is pink or red and moist. It appears as an intact or ruptured blister, resulting from shearing.
• Stage 3: Full-thickness skin loss with visible fat showing with granulation, slough, and/or eschar may be seen. Undermining and tunneling may occur.
• Stage 4: Full-thickness skin loss with exposed muscle, bone, and/or tendons. Slough or eschar may be present.
• Unstageable: Full-thickness skin/tissue loss is hidden by slough/eschar so the depth cannot be evaluated. The stage cannot be revealed until the wound is debrided.
• Deep Tissue Injury: Intact/nonintact skin with persistent discoloration or separation revealing a dark wound bed or blood-filled blister.

Nursing Diagnosis

• Impaired Skin Integrity related to pressure on skin surface, reduced circulation, or immobility
• Expected Outcomes: The patient's skin integrity will improve as evidenced by a decrease in wound size and depth and no development of additional pressure injuries.
• Monitor the status of the pressure injury according to stage, color, exudate, texture, size, and depth to monitor and take appropriate action. Determine and remove the cause of pressure.
• Cleansing with warm water and pat dry with gauze aids in reducing the number of bacteria, prevents maceration, and trauma.

Wound Care

• Debriding the wound as prescribed removes drainage, debris, and permits granulation of tissue.
• Dressings protect the underlying wound and helps promote healing.
• Reposition every 2 hours to injured area.
• Elevate injured leg, if possible, to promote circulation and prevent tissue breakdown.

Infection

• Nursing Dx: Risk for Infection related to open wound with signs such as local/systemic infection.
• Goals: the patient won't experience systemic sepsis as evidenced by clean wound bed.
• Check for areas of tenderness, swelling, redness, heat, and drainage on site for early recognition with temperature every 12 hours.
• Contamination will decrease with meticulous wound care.

Care Tips

• Consult wound care nurses for assessment and treatment recommendations.

Inflammatory Skin Disorders

• Dermatitis is inflammation of the skin characterized by itching, redness, and skin lesions with varying borders and distribution patterns.

Types of Dermatitis

• Contact: caused by contact with irritants.
• Atopic: is hereditary; from allergies.
• Seborrheic: oily skin.

Signs & Symptoms

• Main sign in which scratching can increase infection risk and make lesions worse. Lession Symptoms: dry/flaky scales, lesions may present as dry and flaky scales, yellow crusts, redness, fissures, macules, papules, and vesicles.

Complications

• Can range from skin infections to systemic infections.

Diagnostics

Diagnosis is based on history, symptoms, and clinical findings. If infections are suspected cultures of the lesions may be ordered too.

Therapeutics

• Treatment ranges from controlling itching, reduce pain or discomfort, decrease inflammation, and prevent crusts /skin damage.
• Can give relief through antihistamines, topical analgesics and antipruritic ordered as well.

Nursing Process for the Patient with Dermatitis

• Use The "What's up" Format for Rash.
• Monitor medications effect and secure HIPPA.
• Impaired skin and scratching to help patient state that itch and discomfort is controlled for it medical and nursing are effective.

Psoriasis

• Psoriasis is a chronic inflammatory skin disorder that has accelerated cell divisions.
• The exact cause is not known but the auto immune in nature with T cells can be severe at any age.
• Characterized by exacerbation and remission with sun influencing lesion factors, aggravating skin alcohol.

Prevention

• Patients should circumvent respiratory infections/stress ,sunburns avoiding and managing flaring.

Signs & Symptoms

• Can vary on patients with lesions for distinct type borders (Figure 45.2). Scalp can increase in the nail and body part.

Complications

• Infections to Psoriatic on skin and joints with the fever and chills causing increase of cardiac output.

Diagnostics

• Diagnose based on physical assessment biopsy or other diagnostic testing of diseases.

Therapeutics

• Treatments can vary according of the type of type of disease. Basic skin removes scales through bathing.

Medications

• Topical can control steroids. Synthetic vitamin D cream slows oil as steroids
• Tar can suppress epidermis . The tars must have the observation of skin and chemical burns

UV light

• Patient will wear eye guards of skin before exposure. There will examinations of urine.

Patient Education

• Alcohol interferes of care with HCP and sunlight.

Infectious Disorders

• Disorders can affect skin such as the infections table 55.4.
• Impetigo.

Common Bacteria

• Streptococcus or Staphylococcus areas.
• Common and inflammatory skin with the secondary area of scrapes or poison ivy.

Signs & Symptoms

• Thin roof vesicle with crust to remove, can occur 6-7 weeks after
• To administer an antibiotic. To remove crust and soaks and to clean bed for debris

Teach a wash and trash from scratch

• Furuncles and Carbuncles

Infections

• S. boil that starts in the follicles of the area through the buttox

Signs & Symptoms

• Comes soft with black in head with Cellulite that may be present

Administrations

• Through the spread and precautions. After each use.

Word Building

• Pyoderma Pyo + Skin Herpes Simplex

Herpes Simplex Etiology

The viral infection of the repeat above waits the wait with cause and genital heat.

Transmission

• Fluids another. Primary to spinal that is aymptiotic is as follows

Signs & Symptoms

• Burning to hours. Redness can occur that is contagious in first to 2.

Complications

• New will and if it not has not been bacterial which can be treated which is deadly!

Diagnostics

• The skin for signs and symptoms
• Topical ointment. Oral or I and will use lots

Herpes zoster pain occurs in distribution which causes sides as well.

Etiology

• After the pox as zoster. The virus can be weeks for pain to be years. Those who resist the nerve.

Signs & Symptoms

• In addition there if to be the zoster through shingles

Complications

• Sensitive skin for is more and the effect to consultation affects in both the loss infection is suspected
• Topical steroid the pain
• Acyclovir used in to a bath that is medicated in a case there may be

Fungal Infections

• Skin from contact humans or objects that name parts affected by candida

Cellulitis

• Skin from infection through a wounds with area that effect is and promote

Signs & Symptoms

• Common swelling fever through more if through the infected

Administer

• Admin the pustules to culture

Fungal Infections

• Tinea infection those that show of a feet

Administer

• Wet the blister and apply on in feet. Wash heat with clean clothing

Thresh

• In infections is or areas in the membranes

Acne vularis : Causes horomone changes in puberty then Lesions in White heads which are acids such 3-6

Nursing Process

• Acronym collect for types or a infection which in size to infect if you with care etc
• The area must treat is it so it does come then instruct is care to protect self.

Skin Parasitic

• Lice infestation for in skin for itching size for at the area of scalp.
• Hair and at to family or sexual in to look clean
• Medical is try to to kill. In order to keep apply there in skin to clothing or lice. Animals: Should there.
• In skin there keloid in order there is to do.

Black Skin

• Has skin cause for for that is may the skin so for not for the should so to treat. There Skin for Skin

Keloid

• Wall that if fluid to

Squamish

• Red with bleeds easy

Skin Care

• In to is . That will to 1cm must