Chapter 32: Pressure Injuries

How much has TJC estimated that is costs to treat pressure injuries in the United States?

$11 billion a year

What does the Joint Commission (TJC) estimate how much to treat a hospital-acquired pressure injury?

$2,000 to $70,000 to treat.

What are the common causes of skin breakdown?

- Age-related changes in the skin - Dryness - Fragile and weak capillaries - General thinning of the skin - Loss of the fatty layer under the skin - Decreased sensation to touch, heat, and cold - Decreased mobility - Sitting in a chair or lying in bed most or all the day - Chronic diseases that decrease circulation - Poor nutrition - Poor hydration - Incontinence (urinary, fecal) - Moisture in dark body areas (skin folds, under breasts, perineal area) - Pressure on bony parts - Poor fingernail and toenail care - Friction and shearing - Edema

What are the different bony prominence (pressure points) when the person is in the Fowler position?

- Back of head - Shoulders - Sacrum - Ischial tuberosities - Heels - Toes

What are the different bony prominence (pressure points) when the person is in the supine position?

- Back of the head - Shoulder blades - elbows - Sacrum - Heels

What are common devices to prevent and treat pressure injuries and skin breakdown?

- Bed cradle - Heel and elbow protectors - Heel and foot elevators - Gel or fluid-filled pads and cushions - eggcrate-type pads - Alternating air mattress overlays - Special beds - Other equipment (Pillows, trochanter rolls, footboards, and other position devices are used.)

What persons are at risk for pressure ulcers?

- Bedfast or chairfast persons - Coma, paralysis, hip fracture - Persons that are agitated or have involuntary movements. - Persons having urinary or fecal incontinence. (urine and contain substances that irritate the skin and lead to skin break down.) - Person's exposed to moisture (urine, feces, wound drainage, sweat, and saliva) - Person's that have poor nutrition - Person's that have poor fluid balance - Persons that have lowered mental awareness. - Persons that have problems sensing pain or pressure. - Persons that have circulatory problems. - Persons that are older. - Persons that are obese or very thin. - Persons that refuse care. - Persons that have a healed pressure injury (more likely to recur.)

What are CMS requirements?

- CMS requires that the person make informed choices. - The center and resident must discuss the person's condition, treatment options, expected outcomes, and problems from refusing treatment. - The center must address the person's concerns and offer options if a certain treatment is refused.

What are complication of pressure injuries that could occur?

- Osteomyelitis - Pain - Amputation - Longer nursing center stays

What are the risk factors that cause pressure injuries and skin break down?

- Pressure - Shearing - Friction - Immobility - Breaks in the skin - Poor circulation to an area - Moisture - Dry skin - Irritation by urine and feces

What are the different sites for pressure injuries?

- Pressure injuries usually occur over bony areas called pressure points. - Common sites include the sacrum and heel. - The ears also are sites for pressure injuries. -I n obese people, pressure injuries can occur in areas where skin has contact with skin. - A pressure injury can develop where medical equipment is attached to the skin for a prolonged time.

What are the different bony prominence (pressure points) when the person is in the sitting position?

- Shoulders - Sacrum - Hips - Ischial - Tuberosities - Feet

What are the different bony prominence (pressure points) when the person is in the lateral position?

- Side of head - Ear - Shoulder - Hip - Greater trochanter - Thigh - Knees - Leg - Malleolus - Heel

What are some pressure ulcer preventions?

-Good nursing care, cleanliness, and skin care are essential - The person at risk for pressure ulcers is placed on a support surface that reduces or relieves pressure. - TJC and CMS require pressure ulcer prevention programs. - CMS requires use of the Minimum Data Set (MDS). - Prevention involves identifying persons at risk and implementing prevention measures for them.

When do pressure injuries occur in people that are at risk?

2 to 6 hours after onset of pressure.

When did CMS announce it would no longer pay for additional costs incurred for hospital-acquired pressure ulcers?

2008

What is TJC's estimate of how many people die a year from pressure injury complications?

60, 000 people die each year. Infection being the most common.

avoidable pressure injury

A pressure injury that develops from the improper use of the nursing process

unavoidable pressure injury

A pressure injury that occurs despite efforts to prevent one through proper use of the nursing process

What is the first sign of a pressure injury of someone with light skin?

A reddened bony area

Braden Scale

A tool for predicting pressure ulcer risk

Persons sitting in chairs should shift their positions every A.) 15 minutes B.) 30 minutes C.) Hour D.) 2 hours

A.) 15 minutes

A pressure injury can develop within A.) 2 to 6 hours B.) 6 to 10 hours C.) 10 to 14 hours D.) 14 to 18 hours

A.) 2 to 6 hours

What is the preferred position for preventing pressure injuries? A.) 30-degree lateral position B.) semi-Fowler position C.) Prone position D.) Supine position

A.) 30-degree lateral position

Which of the following contribute to the development of pressure injuries? A.) Shear and friction B.) Slough and eschar C.) Bony prominences D.) CMS and TJC

A.) Shear and friction

Pressure injuries are the result of A.) Unrelieved pressure B.) Moisture C.) Medical devices D.) Aging

A.) Unrelieved pressure

Inflammation of the bone and bone marrow is A.) Osteoporosis B.) Osteomyelitis C.) Myositis D.) Myalgia

B.) Osteomyelitis

Besides heel and foot elevators, which are used to keep the heels and ankles off of the bed? A.) Bed cradles B.) Pillows C.) Heel protectors D.) Eggcrate-type pads

B.) Pillows

A person's care plan includes the following. Which should you question? A.) Reposition the person every 2 hours B.) Scrub and rub the skin during bathing C.) Apply lotion to dry areas D.) Keep linens clean, dry, and wrinkle free

B.) Scrub and rub the skin during bathing

Which of the following is not a prevention measure for pressure injuries? A.) Reposition the person at least every 1 to 2 hours B.) Keep the heels and ankles off the bed C.) Massage bony areas D.) Change linens and garments as needed

C.) Massage bony areas

Which are not used to treat pressure injuries? A.) Special beds B.) Gel or fluid-filled pads and cushions C.) Plastic drawsheets and waterproof pads D.) Heel and elbow protectors

C.) Plastic drawsheets and waterproof pads

Which is the most common site for a pressure injury? A.) Back of the head B.) Hip C.) Sacrum D.) Heel

C.) Sacrum

bedfast

Confined to a bed

chairfast

Confined to a chair

Which is correct for preventing or treating pressure injuries? A.) Use hot water when bathing B.) Allow the person to stay in one position during the night C.) Keep the head of the bed raised as long as possible D.) Make sure shoes fit properly

D.) Make sure shoes fit properly

A person is sitting in a chair. The feet do not touch the floor. What should you do? A.) Have the person slide forward until the feet touch the floor B.) Let the feet dangle C.) Stack pillows under the person's feet D.) Position the feet on a footrest

D.) Position the feet on a footrest

You see a reddened area on the person's skin. What should you do? A.) Rub or massage the area B.) Apply a moisturizer C.) Apply a moisture barrier D.) Tell the nurse

D.) Tell the nurse

When repositioning a person, you should position him or her A.) On an existing pressure injury B.) On a reddened area C.) On tubes or other medical devices D.) Using assistive devices

D.) Using assistive devices

slough

Dead tissue that is soft and often moist and appears white, yellow, green, or tan; tissue may be firmly attached or loose and stringy

What are the other terms for pressure injury?

Decubitus ulcer, bed sore, pressure sore, and pressure ulcer

Avoidable pressure injury

Develops because of improper nursing.

Unavoidable pressure injury

Develops despite proper nursing efforts.

30-degree lateral position

Pillows are placed under the head, shoulder, and leg. This position inclines (lifts up) the hip to avoid pressure on the hip. The person does not lie on the hip as in the side-lying position.

Special beds

Some beds have air flowing through the mattresses. The person floats on the mattress. Body weight is distributed evenly. There is little pressure on body parts.

Alternating air mattress overlays

Some beds may have a special air mattress overlay applied.

What are the different stages of pressure injuries?

Stage 1: The skin is red in persons with light skin. In persons with dark skin, skin color may differ from surrounding areas. Stage 2: Partial-thickness skin loss; it may involve a blister or shallow ulcer Stage 3: Full-thickness skin loss; subcutaneous fat may be exposed. Slough may be present. Stage 4: Full-thickness tissue loss with muscle, tendon and bone exposed and damaged. Slough and eschar may be present. Unstageable: Full-thickness tissue loss with the ulcer covered by slough and/or eschar. Suspected deep tissue injury—purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear

What healed stages does the CMS believe are colonized with bacteria?

Stage 2, 3, and 4

What healed stage are pressure injuries likely to recur?

Stage 3 or Stage 4

pressure injury

localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. Injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear

What are the different bony prominence (pressure points) when the person is in the prone position?

- Check and ear - Acromial processes - Breasts (women) - Elbows - Ribs - Anterior superior iliac spines - Genitalia (men) - Thighs - Knees - Toes

What are CMS standards about pressure ulcers?

- Nursing centers must evaluate each person's condition and pressure ulcer risk factors. - Identify and implement a comprehensive care plan and measures that meet the resident's needs and goals. - The care plan must include measures to reduce or remove a person's risk factors. - Centers must monitor and evaluate the effect of these measures and revise them as needed - Residents with a pressure ulcer must receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

bony prominence

An area where the bone sticks out or projects from the flat surface of the body

In a light-skinned person, the first sign of a pressure injury is A.) A blister B.) A reddened area C.) Drainage D.) Gangrene

B.) A reddened area

The nurse tells you that the person's pressure injury is colonized. This means that A.) The wound is infected B.) Bacteria are present C.) The person has osteomyelitis D.) The person has a wet-to-dry gauze dressing

B.) Bacteria are present

A pressure injury is A.) An open wound B.) Localized damage to the skin and underlying soft tissue C.) A bony prominence D.) Dead tissue

B.) Localized damage to the skin and underlying soft tissue

CMS

Centers for Medicare and Medicaid Services

The following are risk factors for pressure injuries except A.) Urinary and fecal incontinence B.) Lowered mental awareness C.) Moisture D.) Balanced diet

D.) Balanced diet

The following are sources of moisture except A.) Urine and feces B.) Wound drainage C.) Perspiration D.) Barrier ointment

D.) Barrier ointment

Eggcrate-type pads

If used, these devices are placed on beds or in chairs or wheelchairs. The foam pad looks like an egg carton. Peaks in the pad distribute the person's weight more evenly.

Who replaced the term pressure ulcer with pressure injury?

In 2016 the National Pressure Ulcer Advisory Panel (NCUAP)

When do pressure injuries usually occur?

Many pressure injuries occur within the first 4 weeks of admission to a nursing center.

MDRPI

Medical device-related pressure injuries

NPIAP

National Pressure Injury Advisory Panel

intact skin

Normal skin without openings or damage.

Who requires a care plan for each person?

OBRA, CMS, and TJC

OBRA

Omnibus Budget Reconciliation Act of 1987

Who requires pressure prevention program?

TJC and CMS

Who believes that friction and shear are not the main causes of pressure injuries?

The Centers for Medicare & Medicaid Services (CMS)

TJC

The Joint Commission

Turn clock in 24 hour time

The clock shows the times to turn the person and to what position.

What is the treatment of pressure ulcers?

The doctor orders wound care products, drugs, treatments, and special equipment to promote healing.

colonized

The presence of bacteria on the wound surface or in wound tissue; the person does not have signs and symptoms of an infection

friction

The rubbing of one surface against another

Heel and elbow protectors

These devices are made of foam padding, pressure-relieving gel, sheepskin, and other cushion materials. They fit the shape of heels and elbows.

Gel or fluid-filled pads and cushions

These devices involve a pressure-relieving gel or fluid. They are used for chairs and wheelchairs to prevent pressure. The outer case is vinyl. The pad or cushion is placed in a fabric over to protect the person's skin. Some covers are two colors. The colors remind the staff to reposition the person.

Heel and foot elevators

These raise the heels and feet off the bed.

eschar

Thick, leathery dead tissue that may be loose or adhered to the skin; it is often black or brown

What devices can cause pressure and friction?

Tubes, casts, braces, and other devices.

shear

When layers of the skin rub against each other; when the skin remains in place and underlying tissue move and stretch and tear underlying capillaries and blood vessels, causing, tissue damage

bed cradle

a metal frame placed on the bed and over the person. Top linens are brought over the cradle to prevent pressure on the legs, feet, and toes.

What dressing do you use for drainage?

absorptive dressing is used.

How does the CMS define a pressure injury?

any lesion caused by unrelieved pressure that results in damage to underlying tissues.

When should you report and record any signs of skin breakdown or pressure ulcers?

at once.

What is the common skin-to-skin sites?

between abdominal folds, the legs, buttocks, the thighs, and under the breasts.

How often must you reposition a person that is chairfast?

every hour

How often must you reposition a person that is bedfast?

every to 2 hours

What temperature should you never put on a pressure injury?

heat

How do pressure ulcers occur in obese people?

in areas where skin has contact with skin.

osteomyelitis

inflammation (itis) of the bone (osteo) and bone marrow (myel).

erythema

redness of the skin

Where on the body does CMS believe is the most common site for a pressure injury?

sacrum

prominence means?

to stick out

What removes slough from a pressure wound?

wet-to-dry gauze