say no to pressure injury(pathophysiology, prevention, management)

pressure injury:
definition
staging
risk factor
pathophysiology
risk assesment
prevention
management

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.

19. 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

20. 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

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

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

23. 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

24. 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

25. Risk Assessment On Admission Changes Condition Regular Interval

26. 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

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

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

29. Skin Assessment Look in, under, and around medical device Check the area of skin fold and garment

30. Skin Assessment 5 key factor for skin assessment color Temperature Texture Pain Moisture

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Pressure Injury Management