Pressure Injury
Write an outcome related to the pt's skin integrity.
- Her wound will become smaller in size and have increased granulation tissue - She will not acquire another pressure injury while in the hospital - She will verbalize understanding of proper wound care - She will consume an adequate diet of 0.8 g per kg of body weight per day of protein to promote wound healing.
What would you expect a stage 3 pressure injury to look like?
A stage 3 injury has full-thickness tissue loss. Subcutaneous fat tissue might be visible, but bone, tendon, and muscle are not exposed. Slough can occur but will not obscure the depth of tissue loss. This is usually a deep crater with undermining or tunneling present
What major factors increase risk for developing a pressure injury?
1. Incontinence/constant skin moisture 2. Immobility 3. Poor nutrition and dehydration 4. Lack of feeling and perception of pain 5. Blood stasis→ certain conditions like diabetes and vascular disease
Elevated skin temperature and perspiration increase risk for pressure injury. Write 4 specific measures to manage the microclimate.
- Applying a barrier cream to sensitive areas - Regularly change wound dressings to manage drainage and prevent contamination into wound from perspiration - Wear breathable clothing/Use light bed sheets to avoid excessive temperatures - Change linens regularly to minimize moisture on skin - Use absorbent underpads and briefs to wick incontinence moisture away from the skin versus trapping moisture against the skin such as with an adult diaper. - Cleanse skin gently after each incontinent episode with water or pH-balanced cleanser. - Avoid excess friction and scrubbing.
Describe 6 interventions aimed at minimizing friction and sheer.
- Unless contraindicated, keep the head of the bed at or below 30 degrees. If the head of the bed is elevated, limit the elevation time. - Use the knee gatch to help keep the torso from sliding down in the bed. - Keep skin well hydrated and moisturized with hypoallergenic lubricating oils, creams, or lotions. - Use transparent film, hydrocolloid dressings, or skin sealants on bony prominences (such as elbows) to decrease friction. - Lubricate or powder bedpans before placing under the patient. - Roll patients to place the bedpan rather than pushing and pulling it in and out.
What interventions can you initiate to protect the pt's heels?
- Utilizing specialized heel suspension boots to reduce - Placing pillows under the calf to suspend the heels of the mattress - Utilizing heel wound dressing pads at first signs of redness
Knowing that she is frail, has right sided weakness, and has a pressure injury, what consultations or referrals could you initiate?
- Wound specialist -Dietary/Nutrition -Physical therapy & occupational therapist - Hospitalist/Urologist about her incontinence management plan... is she is a good candidate for something like a suprapubic catheter → this patient is immobile and has paresthesia from a stroke, and is fecal and urinary incontinent (risks that are NOT going away) - Specialty bed assessment
What do you feel would be the best choice for dressing her wound?
Alginate, silver, foam, Medihoney, Hydrocolloid, Hydrogel, Hydrofiber Can put gauze, mepilex, or abdominal pads over wound to protect it from exterior environment
What problems can be created by packing a wound too full?
As wounds heal, they contract. If a wound is packed too tightly, it creates a pressure insult to the wound bed and causes a secondary pressure injury or further tunneling.
ach health care setting should have a policy that outlines how to assess a patient's risk for developing a pressure injury. What should be included in that assessment?
Braden Scale- This is a skin injury risk scale that ranges from 9 (highest risk) to 23 (lowest risk) and assesses the following: Sensory Perception (sensing discomfort from pressure) -------Scale 1 (completely limited) to 4 (no impairment) Moisture (is the skin exposed to moisture, usually related to continence status) -------Scale 1 (Constantly moist) to 4 (rarely moist) Activity (What is their degree of activity) --------Scale 1 (bedrest) to 4 (Walks frequently) Mobility (ability to move body in bed) --------Scale 1 (Completely immobile) to 4 (No limitation) Nutrition (USUAL food intake pattern) ------Scale 1 (Very poor) to 4 (Excellent) Friction/Shear -----Scale 1 (Problem) to 3 (No apparent problem)
What are the advantages of using a validated risk assessment tool to document her skin condition on admission?
Consistency/Repeatable: Using a validated risk assessment tool on admission and thereafter for her admission leads to consistency in documentation because everyone has the same prompt. No errors: A validated risk assessment tool has each of the necessary sections that need to be documented on to ensure proper documentation. If the tool is not used, there could be a skin issue that was there upo admission that was not documented. If that skin injury is not documented right away but is then documented later, it would be blamed on the hospital for not properly turning or preventing HAPI's.
What wound documentation is necessary at this time?
Location, undermining or tunneling, tissue type, periwound condition, cleansing agent used -Dimensions of the wound -Stage of the wound -Dressing used -Characteristics of the wound/dressing -Dry, intact, what type of drainage -When a dressing change is due next
What risk factor does using a draw sheet prevent?
Draw sheets are placed under the patient's pelvic area and are used to pull patients up to the head of the bed. When used they prevent friction due to the patient being lifted and not dragged across the sheets when being repositioned.
Compare friction v. shear.
Friction: force of rubbing two surfaces together Shear: gravity force pushing down on the patient's body with resistance between the patient and the surface they are on Both: can cause blistering, excoriation (look for irregular shapes and undermining→ those wounds are usually due to friction/shear)
The pt has very dry, thin, transparent skin. Limited mobility from her stroke and is bedridden. She has several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. She has a hx of urinary and fecal incontinence. Use the Norton scale to rate her:
I would give the pt an 8 using the Norton scale. This means she is at a VERY high risk for developing a pressure injury and should be treated appropriately to prevent another one. 1, Frequent turning 2, Adequate nutrition 3. mproving mobility 4. Keeping clean and dry
Why do the heels have the greatest incidence of breakdown, even when a patient is on a specialty mattress?
Patient's heels are always touching the bed and do not have much skin or fat between the rigid bone. Even with a specialty bed, that constant friction and pressure on the bed can cause dry and thin skin to break down very easily.
As part of pt's admission assessment, you conduct a skin assessment. What areas of her body will you pay particular attention to? (note: the pt has a stage III right hip pressure injury)
Right Hip: Since she already has a known stage III right hip pressure injury, it is especially important we make sure it does not negatively progress to a stage IV pressure injury. Sacrum: This is the most common place for a pressure injury as it is typically the area that experiences the most moisture, friction, and pressure while in bed. Heels: This is a commonly overlooked area on a patient's body while they are in bed. As the pt is a frail woman, there is a thin layer of skin on the heel, making it even easier to acquire a HAPI while admitted. Any skin folds: even though she is frail, she may still have skin folds especially in the groin, under breast, etc.) Any external devices: even a hospital bracelet/blood pressure cuff, restraints, IVs, insulin pumps, ostomies, ports/ tubes need to be thoroughly assessed for skin breakdown
Complete an example of a documentation entry for her wound care.
Stage III pressure injury located on R.L.'s right hip with tunneling. The wound nurse consulted and evaluated. Wound nurse removed the old dressing via push-pull method. Adhesive remover wipes used. After taking off the outside dressing and primary dressing, she stated that "R.L. has a tunneled wound that was packed too hard". Wound visualized by two nurses. Dimensions: 7cmx 5cm x 1cm. Moderate yellow drainage with no foul odor. Obtained a set of wound cultures and sent to the lab as per order. Wound nurse repacked the wound with gauze. Dressing is now clean and intact. Wound nurse recommends all nursing staff to maintain dressing, with only wound nurses changing the dressing. Patient placed on specialty mattress and q2h turns initiated. Extremities offloaded with pillows. --Stage of wound, tissue type, periwound condition, cleansing agent used, dressing type used.
The nurse systematically assesses the injury and confirms the presence of a stage 3 wound with moderate yellow drainage. There is no tissue necrosis or debris. What does it mean to stage a wound?
Staging involves noting the different tissue layers involved in the insult. Stage 1- intact skin with non blanchable redness Stage 2- loss of dermis, red/pink Stage 3- subcutaneous fat visible but no exposed muscle, tendon, or bone Stage 4- exposed bone, muscle, or tendon Unstageable- the base of the wound is covered by necrotic tissue Suspected deep tissue injury- discolored intact skin or blood filled blister
Why is a specialty mattress used for immobile patients?
To relieve pain/pressure on bony prominences and areas of the body prone to pressure injuries. If a patient is immobile, they are going to be on these bony prominences for extended periods of time. A specialty mattress will be made of a softer material to help distribute body weight more evenly. Some mattresses will inflate/deflate to turn these patients as well.
What is a tunneling wound? What risk factors are associated with tunneling?
Tunneling wounds have channels that extend into surrounding fat/tissue/muscle often as a result from infection. Risks include: - Deficient collagen formation (could be due to medications like corticosteroids) - Use of NSAIDS (they slow down protein synthesis) - Inappropriate packing/dressing - Comorbidities including diabetes, malignancies, and obesity
Why are patients placed on specialty mattresses still at risk for skin breakdown?
While it moves air around underneath the patient, it does not replace the need for frequent repositioning and turning.
What factors influence the choice of a wound dressing?
Wound related factors ----Wound type (superficial, full thickness, cavity) ----Wound characteristics (dry, moist, malodorous, painful) -----Wound description (necrotic, sloughy, granulating) -----Bacterial profile (sterile, infected, colonized) Product related factors: -----Conformability ------Fluid handling properties -----Odor absorbing properties -----Ease of use ------Antibacterial activity Patient related factors ------State of continence -----Sensitivity to medical dressings ------Fragility of skin -----Need to bathe/Shower frequently -----Compliance ------Do they have access to materials needed
Describe the technique for packing a tunneled wound.
You would use a wet-to-dry dressing. The wet dressing should be moist but not dripping, and very gently put into the wound filling any open space but not tightly jammed in. A dry dressing would be placed over the wet dressings.
When collecting a wound culture with a swab, the nurse should culture the: a. Wound drainage b. Healthy appearing tissue c. Most necrotic appearing tissue d. Very outer edges of the wound
b. Healthy appearing tissue Culture the healthiest-appearing tissue in the center of the wound.
Which instructions will you give the UAP? Select all that apply. a. Assess R.L.s skin status every shift b. Develop an every-2-hour turn schedule→ you would want the UAP to help maintain a q2 hour turn schedule, however they don't "develop" it c. Use the appropriate sheets on the airflow beds d. Keep HOB below 30 degree angle e. Assist with hygiene measures when R.L. is incontinent f. Empty and measure output in the urine collection device
c. Use the appropriate sheets on the airflow beds d. Keep HOB below 30 degree angle e. Assist with hygiene measures when R.L. is incontinent f. Empty and measure output in the urine collection device
