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Pressure Injuries Lecture Notes

Jul 22, 2024

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  • Topic: Pressure injuries (often referred to as pressure ulcers in outdated texts)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.