Pressure Injuries Training Outline
Kelly Sturgeon, Administrator
Creekside Cottage Lic 496803346 and Creekside Place Lic 496803441
3/7/24
Source: NIH
Objectives:
- Differentiate the four stages of pressure injuries.
- List the most common sites for pressure injuries.
- Summarize the treatment options for pressure wounds.
- Explain the importance of improving care coordination among interprofessional team members to ensure proper pressure injury prevention protocols are in place and enhance surveillance in order to optimize outcomes for patients with pressure wounds.
Introduction
Wound pressure injuries have been given various names over the last several years. In the past, they were referred to as pressure ulcers, decubitus ulcers, or bed sores; and now they are most commonly termed “pressure injuries.” Pressure injuries are defined as the breakdown of skin integrity due to some types of unrelieved pressure. This can be from a bony area on the body coming into contact with an external surface which leads to pressure injury. These wounds represent the destruction of normal structure and function of the skin and soft tissue through a variety of mechanisms and etiologies. The wound healing process is affected by various factors including infection, the presence of chronic diseases like diabetes, aging, nutritional deficiency like vitamin C, medications like steroids, and low perfusion of oxygen and blood flow to the wound in cases of hypoxia and cold temperature. Pressure ulcers result from long periods of repeated pressure applied to the skin, soft tissue, muscle, and bone. In pressure ulcers, the external pressure exceeds capillary closing pressure.[1][2][3]
Anatomy and Physiology
Elderly and bed-bound individuals are more prone to developing pressure (decubitus) ulcers. The hip and buttock region accounts for approximately two-thirds all pressure ulcers. Also, the skin underneath the nasogastric or endotracheal tubes might be affected by pressure ulcers. They are slightly more predominant in females than males. Pressure ulcers are caused by a prolonged period of repeated friction and shearing pressure of the skin overlying the bony prominences along with some of the following intrinsic causes:
- Loss of skin fragility
- Decreased blood flow
- Loss of muscle volume
- Spinal cord injuries
- Nutritional insufficiency
- Moisture due to fecal and/or urinary incontinence
Understanding how a pressure injury happens requires a review of the basic layers of the skin. The epidermis is the most superficial layer. Just below the epidermis is the dermis, and then right below the dermis is the capillary bed which feeds, perfuses, and supplies the dermis and epidermis. Below the capillary bed is the fatty subcutaneous tissue, followed by muscle and then bone. Hence, in a patient who is sitting in the chair for a really long time, the coccyx bone which is obvious the bony prominence is going to place the patient at risk for developing a pressure injury by exerting upward pressure on bottom skin layers. In addition, there is the external hard surface of the chair that can also place pressure on the skin and bony prominences. If the pressure is prolonged, it can compromise blood supply to the skin.
It is very important to avoid friction and shear force injuries. These injuries may occur when the patient is sliding down in the bed. For example, when the coccyx bone is moving upwards and the skin is moving downward (i.e., the two forces move in opposite direction), the middle layer which supplies and perfuses the dermis and epidermis may tear, leading to decreased perfusion and eventually resulting in a pressure injury. There are various stages of pressure injury, all of which classify the injury based on the depth of skin injury. Pressure ulcers are categorized into four stages:
- Stage 1: just erythema of the skin
- Stage 2: erythema with the loss of partial thickness of the skin including epidermis and part of the superficial dermis
- Stage 3: full thickness ulcer that might involve the subcutaneous fat
- Stage 4: full thickness ulcer with the involvement of the muscle or bone
The most common sites for pressure injuries include the sacrum (tailbone) followed by the heels, trochanter (hip bone), and the ischium (sitting erect bone), especially in paraplegic patients.
Prevention
Proper repositioning is essential in maintaining skin integrity and is needed in patients who are unable to do this for themselves. Pressure, friction, and shear forces should be avoided during positioning. The most effective way of repositioning is to move the patient every 2 hours so that the ischemic areas can recover. This can be done with the use of pillows or wedges to keep the patient on their side and placing pillows between their legs and under their calves helps take pressure off their back, buttocks, medial aspect of the knees, and heels. Hygiene and moisture reduction are very important, especially for patients who are incontinent; excess moisture is known to cause the skin to break down, and the patient must always be kept dry. This job falls on the nursing assistants who are responsible for making sure the patient is clean at all times. If patients develop skin breakdown due to moisture, the nurse is at fault for not properly delegating and overseeing the nursing assistants.
Goals
The primary goal is to prevent pressure ulcers through various means including the use of air-fluidized or foam mattresses, improving the nutritional status of the patients, proper placing of patients in bed, changing position frequently, and treatment of the underlying diseases.