Pressure Injuries

Introduction

• Presenter: Cathy from Level Up RN
• Topic: Pressure injuries (often referred to as pressure ulcers in outdated texts)
• Importance: Relevant for nursing school and practice, especially in acute care settings (med-surg or ICU)
• Key Areas Covered:
  • Pathophysiology
  • Risk Factors
  • Staging
  • Treatment
  • Nursing Care
• Additional: Quiz at the end for review
• Tools: Level Up RN Medical-Surgical Nursing Flashcards

Pathophysiology

• Definition: Injury to skin/underlying tissue due to prolonged/intense pressure
• Common Locations: Bony prominences (coccyx, heel); can also be from medical devices
• Mechanism:
  • Compression of tissue
  • Impaired blood flow
  • Inadequate perfusion/oxygenation
  • Cell death

Risk Factors

• Impaired nutrition
• Reduced sensation (e.g., neuropathy)
• Excess moisture (e.g., incontinence)
• Immobility
• Impaired oxygenation
• Friction and shear forces
• Assessment: Norton Scale or Braden Scale
  • Norton: Score ≤ 14
  • Braden: Score ≤ 18
• Action: Special precautions for at-risk patients

Staging of Pressure Injuries

• Stage 1:

  • Damage to epidermis
  • Intact skin with nonblanchable erythema (redness)

• Stage 2:

  • Damage to epidermis and dermis
  • Open wound with partial-thickness skin loss
  • Base often red and moist
  • May present as a serous-filled blister

• Stage 3:

  • Damage extends to subcutaneous tissue
  • Full-thickness skin loss with visible adipose tissue
  • Muscle, tendon, bone not visible
  • Possible undermining or tunneling

• Stage 4:

  • Full-thickness skin loss
  • Exposed bone, tendon, or muscle
  • Possible undermining or tunneling

• Unstageable:

  • Necrotic tissue covers wound base (slough or eschar)
  • Depth unknown until debridement

• Deep Tissue Injury (DTI):

  • Damage at bone-muscle interface
  • Intact or nonintact skin with purple/maroon discoloration
  • May present as a blood-filled blister

Treatment

• Primary Action: Remove pressure to restore blood flow
• Dressings: Protective dressings over the wound
• Debridement: Necessary if necrotic tissue present
• Other Therapies:
  • Negative-pressure wound therapy (wound VAC)
  • Hyperbaric oxygen therapy
  • Skin grafts or flaps

Nursing Care

• Specialty mattress for pressure redistribution
• Frequent repositioning (every 2 hours)
• Head of bed < 30 degrees to decrease shearing forces
• Do NOT massage bony prominences
• Ensure adequate nutrition (especially protein)

Quiz

• Question 1: What stage is a pressure injury with full-thickness skin loss and visible bone?
  • Answer: Stage 4
• Question 2: What stage is a pressure injury with intact skin and nonblanchable erythema?
  • Answer: Stage 1
• Question 3: What stage is a pressure injury where the wound base is covered in eschar?
  • Answer: Unstageable

Conclusion

• Encouragement to subscribe, share, like, and comment.