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Pressure Injury
- 1. PRESSURE INJURY Dr Vidhya D Pillay Resident Physician Department of Geriatric Medicine Khoo Teck Puat Hospital 24th April 2017
- 2. DEFINITION • ‘Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device’ – National Pressure Ulcer Advisory Panel (NPUAP) (2016) • ‘An area of localized damage to the skin, muscle and underlying tissue caused by shear, friction or unrelieved pressure, usually over bony prominences’ – MOH CPG (1993)
- 3. ANATOMY • Hip and Buttock regions (70%) – Ischial tuberosity, trochanteric and sacral areas • Lower extremities (15-25%) – Malleloar, patellar, heel and pretibial areas • Nose, chin, forehead, occiput, chest, back and elbow (5%)
- 4. SKIN AND THE AGING PROCESS Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 5. Too much pressure is applied to one area Deprives tissues of oxygen and nutrients Cell Death Tissue necrosis Stop capillary flow to the tissues. PROLONGED PERIOD OF TIME PATHOPHYSIOLOGY Interface Pressure is the pressure of body pressing the skin down onto a firm surface Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 6. PATHOPHYSIOLOGY • Many factors contribute to the development of pressure injuries but pressure leading to ischaemia and necrosis is the final common pathway • Pressure injuries result from the constant pressure sufficient to impair local blood flow to soft tissue for an extended period
- 7. PATHOPHYSIOLOGY • Tissues are capable of withstanding enormous pressures for brief periods but prolonged exposure to pressures just slightly above capillary filling pressure initiates a downward spiral toward tissue necrosis and ulceration • Inciting event is compression of the tissues against external objects such as a mattress, wheelchair pad, bed rail or other surfaces
- 8. SHEARING • Shearing – Pressure that occurs when layers of skin are forced down or when the patient is pulled up or out of a bed, chair or wheelchair • Caused by gravity and friction • Decreases of stops blood flow through the vessels Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 9. FRICTION • Friction – Pressure caused by mattress or clothing rubbing against the surface of the skin • When two surfaces rub together • Common sites – Elbows – Heels Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 10. MOISTURE • Wet skin softens and breaks open more easily • Wet skin can cause rashes and increase the risk of breakdown Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 11. RISK FACTORS • Impaired mobility • Contractures and spasticity • Inability to perceive pain • Pain • Quality of skin • Incontinence or presence of a fistula • Bacterial contamination
- 12. RISK FACTORS • Malnutrition • Hypoproteinaemia • Anaemia • Peripheral vascular disease • Hypovolaemia
- 13. BRADEN SCORE • A low score indicates high risk - Very High Risk : <10 - High Risk : 10 – 12 - Medium Risk : 13 – 14 - At Risk A : 15 –16 At Risk B : 17 – 18 - Low or No Risk : >19 Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 14. PRESSURE INJURY - STAGING Source: https://www.drugs.com/health-guide/bedsores-decubitus-ulcers.html
- 15. PRESSURE INJURY - STAGING • UNSTAGEABLE ULCER – Full thickness tissue loss with base covered by slough and/or eschar Source: https://members.nursingquality.org/ndnqipressureulcertraining/Module1/Unstageable1.aspx
- 16. PRESSURE INJURY - PREVENTION 1. Pressure Relief Device (Mandatory/Optional) 2. Heel protectors (Mandatory/Optional) 3. 2 hourly turning 4. Dietitian referral (score of 14 & below) 5. Wound nurse referral if wound is present 6. Skin care * Mandatory for High Risk & Very High Risk groups (score of 12 & below) * Optional for At risk A group (score of 15-16) and Medium Risk group (13-14) Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 17. PRESSURE INJURY - PREVENTION • Report unusual skin conditions – Inspect the skin every shift and report the findings – Meticulous skin check especially of the non obvious visual areas Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 18. POSITIONING OF PATIENTS Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 19. POSITIONING OF PATIENTS Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 20. POSITIONING OF PATIENTS Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 21. POSITIONING OF PATIENTS Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 22. INCONTINENCE ASSOCIATED DERMATITIS (IAD) • Skin damage associated with exposure to urine and stool • Distinguishes skin problems associated with incontinence vs other conditions • If the patient is not incontinent, the condition is not IAD Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 23. INCONTINENCE ASSOCIATED DERMATITIS (IAD) • With exposure to urine and faeces, there is overhydration of the skin causing swelling and disruption of stratum corneum • Increases skin pH and creates inflammation • Disruption of normal barrier structure and function Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 24. INCONTINENCE ASSOCIATED DERMATITIS (IAD) Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 25. INCONTINENCE ASSOCIATED DERMATITIS (IAD) • Assess skin for : – Maceration – Erythema – Signs of fungal or bacterial infection – Presence of lesions – Erosions or denudations • Document findings and elicit appropriate management Source: Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 26. IAD VS PRESSURE INJURY Source: http://www.nursingcenter.com/cearticle?an=00152192-201201000-00010
- 27. REFERENCES 1. http://emedicine.medscape.com/article/190115 2. https://www.drugs.com/health-guide/bedsores- decubitus-ulcers.html 3. https://members.nursingquality.org/ndnqipressure ulcertraining/Module1/Unstageable1.aspx 4. http://www.nursingcenter.com/cearticle?an=00152192- 5. Pressure Injury Presentation by NC Mary Chan on 24th Feb 2017
- 28. THANK YOU
Editor's Notes
- Skin Lifespan Changes Skin becomes scaly Age spots appear Epidermis thins Dermis becomes reduced Loss of fat Wrinkling Sagging Sebaceous glands secrete less oil Melanin production slows Hair thins Number of hair follicles decreases Nail growth becomes impaired Sensory receptors decline Body temperature unable to be controlled Diminished ability to activate Vitamin D
- Pressure relieving mattress, Use heel protector, Avoid sitting on chair for prolong period, Need assistance should be repositioned at least hourly or put back to bed, Patient able to sit out, teach to shift their weight every 15mins Nurse on pressure-relieving mattress, Turn 2 hourly, Use pillows to keep bony prominences from direct contact with one another Prop patient up at 30 degrees (unless contraindicated), Use lifting devices and aids and correct lifting techniques during transfer and repositioning, Encourage patient to ambulate with assistance if needed Inspect the areas over the bony prominences when attending to patient, Keep patient clean and dry, Cleanse and change patient when soiled, Place absorbent pads, Incontinent patient, Excess wound drainage, Apply barrier cream and moisturizer when necessary, Use sheath or urinary catheter if necessary or as ordered, Keep bed sheets dry and wrinkle-free at all times Assess patient’s nutritional status, Weigh patient on admission and weekly if fit, Refer to dietitian for nutritional assessment for the “at risk” patient, Encourage oral intake if patient is not taking well, Document and inform doctor and dietitian if the patient’s dietary intake remains insufficient