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Pressure injuries (Nursing management (Optimise nutrition and hydration…
Pressure injuries
Nursing management
Assess risk for all residents
Braden scale assessment
This assessment has the best validity ad reliability indicators
Braden scale assessment should be reviewed every three months
Head-to-toe assessment
Assess on admission and at periodic intervals dependent on the residents condition
Inspect skin integrity
The integrity of skin can deteriorate in a matter of hours. Sacrum, heels, buttocks, back of head, ears, back and elbows are areas most commonly affected
.
Nursing action includes
:
Daily checks of skin integrity during hygiene cares
Ensure HCAS are aware of observing and reporting any changes in skin integrity in the progress notes
Ensure all documentation is completed i.e. wound assessment and care plans
Positioning and re-positioning
Educate residents on the importance of actively mobilising and independently changing their position.
Residents who are not independently should have a documented position change regime every 1-3 hours.
Avoid shear and friction during lifting and moving procedures by using a slippery sam
Optimise nutrition and hydration
Poor nutrition and dehydration can lead to pressure injuries.
A fluid and nutrition assessment should be completed on admission and reviewed every three months.
Minimal goal of fluid is 1.5L per day.
Daily oral supplements should be considered for residents at high risk of those recovering from an injury.
Manage moisture
Excess moisture leads to rashes and can speed up the breakdown process
.
Prolonged moisture decreases tissue tolerance thus making it less resilient to shearing and friction.
Skin should be kept clean and dry at all times. Residents should have specific interventions to facilitate this outcome i.e. toileting regime, barrier cream, and correct documentation.
Treatment
Selection of wound dressings is based on wound size, location, exudate, odour, pain, and infection.
There are many dressing products available with different forms of promoting a healing environment i.e. hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, and soft silicones.
Water-based skin emollients maintain skin hydration.
Infections should be treated with antimicrobial therapies such as topical agents (e.g. cadexomer iodine and honey).
Regardless of the dressing used, the injury would not heal if the there is no off-load from the area.
Stage 2
A broken top layer with either a red or pink wound. Often presented as a blister and may weep clear fluid
.
A shallow open wound that is either red or pink in colour
May also present intact or as a ruptured blister
Resident case study
Stage 2 pressure injury
Length = 0.7 cm
Width = 0.2 cm
Location = Sacrum
Management:
NACL cleanse
Allevyn wound dressing to promote healing
Wound rechecked in three days
Treatment plan and goal
To prevent further damage, while allowing the top layer of skin to heal
Implement treatment plan for stage 1
Apply dressing to promote healing
Protect fragile skin from adhesive
Stage 3
A deep wound which penetrates near the bottom of the skin. Muscle, tendon, bone, fat, or cartilage may be seen.
Tissue loss
Slough may be present
Depth depends on location of injury i.e. nose and ears
Could present as a shallow injury
Resident case study
Stage 3 pressure injury
Length = 2 cm
Width = 2 cm
Location = Right heal
Slough necrotic tissue present
Cliff wound
*
Management:*
Normal saline
Allevyn wound dressing to promote healing
Cuticerin gauze dressing
Wound rechecked in three days
Treatment plan and goal
To prevent or treat infection and allow new tissue to grow
Implement treatment plan for stage 1 and 2
Remove dead tissue
Absorb drainage
Fill the ulcer cavity
Recommend nutritional consultation
Stage 1
An area of the skin that remains red when pressed (non-blanchable). Swelling may also be seen.
Skin is intact
Found over a bony prominence
Non-blanchable redness
Localised area
The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue.
Treatment plan goal
To prevent skin breakdown and restore the skin's blood supply
Relieve pressure and prevent shear and friction
Prevent build up of surface moisture
Cleanse and lightly lubricate
Apply protective dressing
Evaluate nutritional intake
Stage 4
The wound extends down to the muscle, tendon, bone or cartilage
.
Full thickness tissue loss
Bone, tendon, or muscle may be seen
Depth varies depending on anatomical location
Treatment plan and goal
To reduce drainage, remove dead tissue, and establish a good climate for new growth
Implement treatment plan for stage 1-3
Consult with physician
Evaluate bone involvement
Recommend antibiotics
Recommend surgical input
Unstageable
A deep wound with a layer of dead tissue (slough). Slough may be yellow, tan, green, or brown.
Full thickness tissue loss
Base of injury is covered by coloured slough
True depth cannot be determined until slough is removed
Suspected deep tissue injury
The top layer of the skin may present as a purple, maroon or navy colour. It may also present as a blood filled blister. The injury may be painful, hard, and warm or cool to touch.
Blood filled blister due to damage below the surface of underlying soft tissue
Colour is localised
Tissue injury may be hard to detect in individuals with dark skin tone
Definition
Pressure injuries are injuries to the skin, caused by localised pressure or pressure combined with either shear or friction.
Muscle is less resistant to pressure changes than skin, thus muscle may necrose prior to skin breakdown
Occurrence of pressure injuries in nursing homes = approximately 26%
Signs and symptoms
Dependent on the extent of tissue involved. Injuries are graded of which depends on the depth of the damage tissue. Stages range from 1-4, unstageable, and suspected deep tissue injury.
Pressure injuries are staged which helps to determine the extent of the damaged skin.
Location
Usually found over a bony prominence. The most common sites of injury is the sacrum and heals. Other sites include ears, back of head, shoulder, shoulder blades, rib cage, spine, ankle, toes.
Risk Factors
Incontinence
Advanced age
Diabetes
Elevated body temperature
Immobility
Impaired circulation
Low diastolic blood pressure
Obesity
Pain
Prolonged surgery
Factors involved
The intensity of pressure
The duration of pressure
The patient's ability to tolerate applied pressure
Shearing force i.e. tissue sliding in the similar direction of body movement
Friction i.e. two surfaces rubbing against each other
Also known as pressure ulcers, pressure sores, decubitus ulcer, or bed sores
.
Sustained pressure can compress underlying tissues between the skin and the skeleton. This pressure can lead to decreasing the capillary blood flow, occlusion of blood vessels, and tissue ischaemia.
