The document defines pressure injuries and their classification. It notes that pressure injuries can develop within 1 week and in as little as 6 hours. 59.2% of pressure injuries were ICU-acquired. Prevention involves frequent risk assessment using tools like the Braden Scale, nutrition management, repositioning, proper support surfaces, dressings, and patient/family education. Pressure injuries are caused by prolonged pressure, friction, and shear impairing blood supply. Management involves treatment according to the stage and risk factor reduction.

1. SAY NO TO
PRESSURE INJURY
DR. KHADIJAH BINTI NORDIN
UNIT PENJAGAAN LUKA, HEBHK
CCWC ( MALAYSIA), PGWM ( ON GOING)

2. OUTLINE
DEFINITION
CLASSIFICATION / STAGING
RISK FACTOR
PREVENTION
RISK ASSESMENT
Management
PATHOPHYSIOLOGY

3. Localized injury to the skin and/or
underlying tissue usually over a bony
prominence, as a result of pressure, or
pressure in combination with shear’
(EPUAP/NPUAP/PPPIA, 2019a).
Definition

4. Impact of pressure injury
To patient
Longer Hospital Stays
Premature Mortality
Higher rate of admission
Greater Pain And Suffering For The
Patient
Financial impact to patient
Physical and Emotionally disturb
Decrease quality of life
Increased risk of infection

5. Pressure injuries Can
develop within 1week

6. Pressure injuries Can
develop in as a little as 6
hours

7. 59.2% of pressure
injuries were icu-
acquired

8. STAGGING
Used to:
• Identify the extent of the depth of tissue loss
and the physical appearance of the injury
• Documentation
• Communication
• Planning for management
Stage 1 Stage 2 Stage 3 Stage 4
Deep tissue pressure injury
Unstageable

9. PRESSURE INJURY AS EASY AS APPLE P.I.E

10. • Intact skin with non-blanchable redness of a localised area
usually over a bony prominence.
• Pain, firmness, softness, or temperature changes can be
noticeable compared to adjacent skin. Darkly pigmented
skin may appear differently.
Stage 1
• Think of a red apple. The red color will not go away
when we touch it.
• This is like a stage 1 pressure ulcer; it will not blanch
because there are already signs of capillary
compromise within the layer of skin.

11. Stage 2
• Partial thickness skin loss (involves epidermis and
dermis) presenting as a shallow open ulcer with a
red-pink wound bed.
• It may present as a clear fluid-filled blister.
• A stage 2 pressure injury does not contain any
slough.
• A stage 2 pressure injury the wound is only into the
dermis or innermost layer but no deeper.
• Think of an apple being peeled where you just
want to remove the skin.

12. Stage 3
• Full thickness loss.
• Subcutaneous fat may be visible, but no bone,
tendon, or muscle is exposed.
• Slough may be present but it does not obscure the
depth of tissue loss.
• This may include undermining and tunneling.
• A Stage 3 pressure ulcer is similar usually with more
depth to these types of wounds.
• Think of what a red apple looks like when you take a
nice healthy bite out of it, you are into the juicy part
of the apple.

13. Stage 4
• Full-thickness tissue loss with exposed bone, tendon,
or muscle. Often includes undermining and tunnelling.
• A Stage 4 pressure ulcer is similar to you down to the
bone, muscle, and tendons.
• Think of a red apple that you happen to bite to the
core.

14. Deep tissue pressure injury
• Intact or non-intact skin with localized area of
persistent non-blanchable deep red, maroon, purple
discoloration or epidermal separation revealing a dark
wound bed or blood-filled blister.
• This is like a deep tissue pressure injury as you know
there is tissue damage even though the skin is intact.
• Think of a bruised apple, the skin is intact, but you
don’t know how bad the apple is underneath, but you
can tell it is damaged.

15. Unstageable
• Full thickness loss in which the base of the ulcer is
covered by slough and/or eschar in the wound bed.
• It is completely unknown what is happening to the
apple underneath.
• This is just like an unstageable ulcer; we don’t know
how deep it is and hence it’s unstageable.
• Think of a toffee apple, where the toffee completely
coats the apple.

16. Mucosal Membrane Pressure Injury
• Mucosal Pressure ulcers are found on the mucosal
membranes.
• They are usually caused by a device used at the
location of the injury.
• Due to the anatomy of the mucous membrane, these
ulcers cannot be staged.
• They are simply called mucosal ulcers.
• Examples include pressure ulcers that develop on the
nasal mucosal (from pressure exerted by oxygen, CPAP,
nasal prongs) or part of the lip or tongue (pressure
exerted by an endotracheal tube).

17. Medical Device-related Pressure Injury
• Medical device-related pressure injuries result from the use of
devices designed and applied for diagnostic or therapeutic purposes.
• Examples- include oxygen masks, tubing, tracheostomy, compression
stockings, and splints/braces.
• Medical device pressure ulcers are staged as above.

18. Incontinent/ Moisture Associated Dermatitis
• These lesions are caused by incontinence or moisture
and are not caused by pressure and/or shear.
• The skin is damp and the damage is not necessarily
located on bony prominences.
• These are often misclassified as pressure ulcers.
• The patient may have a combination of pressure
damage and incontinence, if pressure damage is
present then stage as appropriate.

20. Pressure
injury
Prolonged
pressure
impair
blood
supply
cells don’t get
enough nutrients and
oxygen
Friction
when a patient is
moving in their bed
two surfaces
rub against one
another
two unaligned forces
move one part of the
body in one direction
and the other in
opposition
causing damage to
tissue deep within
the skin
Shear
excess of moisture
which may include
sweat, urine, feces, or
excessive exudate
makes the stratum
corium more
suspectable to
damage
lead to maceration of
the skin over time

21. Factor That Contribute To Pressure Injury
EXTRINSIC RISK
INTRINSIC RISK
PRESSURE FRICTION SHEAR MOISTURE MEDICAL DEVICE
PREVIOUS
PRESSURE INJURY
SPINE
INJURY
EXTREME OF AGE DIABETES IMPAIRED
PERFUSION
OBESITY

22. Patient That Risks To Get Pressure Injury
Limited mobility Long-term care needed Diabetes
Trauma Hip fracture
Spinal injury

23. How long the patient can develop
pressure injury depends on
Intensity of pressure and shear force
Duration of the force
Susceptibility of the patient

24. Risk Assessment
An essential component of a pressure injury prevention
program
Along with clinical judgment, risk assessment tools are
designed to quantify a patient’s risk of developing a
pressure injury

25. Risk Assessment
Braden Scale
Very
high
High Moderate Mild
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
An essential component of a pressure injury prevention
program
Along with clinical judgment, risk assessment tools are
designed to quantify a patient’s risk of developing a
pressure injury
Use a validated risk assessment tool such as the braden
Scale

26. Risk Assessment
On Admission Changes Condition Regular Interval

27. How to assess a pressure injury
Perform a visual head-to-toe assessment focusing on
bony prominences.
Check around medical devices.
Documentation of pressure injury according to the
protocol of your facility

28. Common areas must check:
How to assess a pressure injury
sacrum Heel Ankle Elbow
Gluteal Hip

29. How to assess a pressure injury
Common areas around medical devices
Nose Ear Mouth/ lips Documentation Finding

30. SkinAssessment
Look in, under, and around medical device Check the area of skin fold and garment

31. SkinAssessment
5 key factor for skin assessment
color
Temperature
Texture
Pain
Moisture

32. Microclimate
• As the temperature of the skin increase
there is an increase in moisture
• Skin strength will decline
• Increased temperature contributes to
skin damage
• Increased moisture contributes to
increased friction

33. Preventative Skin Care
• Cleanse skin with pH pH-balanced
product
• Moisture the skin
• Protect skin from moisture with a
barrier production
• Used high absorbency incontinent
product

34. Component for reducing the risk of pressure
injuries
Bed linen/textile
selection
Nutritional
assessment and
management
Repositioning and
early mobilization
Support surface
selection and use
Prophylactic
dressing
Medical device
assessment and
management
Education for clinical
staff, patients and
family

35. Assess and optimize nutritional status
Inadequate nutrition can be caused by:
• Loss of appetite or interest in food
• Medication and medical condition
• Inability to feed themselves
Be sure to:
• Frequently assess nutritional status, monitor intake
• Create a nutritional care plan
• Collaborate with dietitian

36. Frequent repositioning and early mobilization
Minimize friction and shear by:
• Keep the head of the bed as flat as possible
• Elevate the knees
• Use low-friction textile
• Minimize the layer of linens
• Lift the patient to avoid sliding or dragging

37. Support surface selection and use
Select a support surface that
meets the individual’s needs
for pressure redistribution
based on:
Level of immobility
and inactivity
Need to influence
microclimate
Shear reduction
Size and
weight
Location and severity
of existing pressure
injuries
Risk developing new
pressure injuries

38. Prophylactic dressing
Used a soft silicone multilayer foam dressing to protect the skin of individuals at risk.
When selecting a dressing consider:
Correct
dressing size
for high risk
location
Ability to
manage
microclimate
Ease of application and removal
Ability to maintain placement
Ability to access
and assess skin

39. Patient and family education
They may look to you to provide information on:
• Prevention plan
• Repositioning
• Skin assessment
• Self-inspection and the importance of reporting
changes in skin integrity

40. Pressure Injury Management