What is the inner layer of skin called and what is its function?
Called the dermis and it provides tensile strength, mechanical support, and protection to underlying muscles, bones and organs
What is stage 1 of a pressure injury?
Injury to tissue without breaking skin, although at high risk of further damage
Where do pressure injuries usually occur?
over bony prominence
What are the causes of pressure injuries?
pressure, shear, friction, or combo of these as well as affected by moisture, nutrition, perfusion, and comorbities
why is it more likely for skin to be torn/pressure injuries to occur for older adults?
because of reduced skin elasticity, decreased collagen, and thinning of underlying muscles tissues
what are the pressure-related factors that contribute to the development of pressure injuries?
- Pressure intensity
- Pressure duration
- Tissue tolerance
describe pressure intensity (#1)
if too much pressure is put over capillaries for an exceeded amount of time, reduction of blood flow (ischemia) can occur and body can therefore lose sensation and won’t be prompted to shift
what is hyperemia?
its redness due to vasodilation and it occurs when pressure is relieved and blood flow returns.
what is blanching hyperemia?
when finger is placed over area and it blanches and then goes back to normal
occurs when normal red tones of light skinned patients are absent (does not occur with darkly pigmented skin)
describe pressure duration (#2)
- low pressures over a prolonged time period
- high intensity pressures over a short period of time. Both equally bad and causes tissue damage
- extended pressure occludes blood flow, nutrients, and contributes to cell death
describe tissue tolerance (#3)
ability of tissue to endure pressure depends on integrity of both the tissue and supporting structures
what are systemic factors that affect tissue tolerance?
poor nutrition, age, decreased BP
what are the risk factors for pressure injury development
- impaired sensory perception: because some may not feel increased, prolonged pressure/pain
- impaired mobility: less mobile= less able to change positions
- alteration in level of consciousness: confused patients hinder ability to understand sensation of pressure and respond by repositioning independently
shear: force exerted parallel to skin and results from both gravity pulling down on body and resistance (friction) between patient and a surface
- friction: force of two substances moving across one another
- moisture: reduces skin resistance
why is nutrition essential for would healing and prevention?
because vitamin A reduces negative effects of steroids on wound healing and calories provide energy to support wound healing
what is tissue perfusion?
oxygen fuels cellular functions essential to healing process. The ability to perfuse tissues with good amount of oxygenated blood is critical to wound healing.
what are factors that can decrease tissue perfusion?
pain, age, psychological impact of wounds.
Pain because of rapid, shallow breathing and tensed muscles.
Age because it will affect the healing trajectory of a would (decrease functioning of macrophages, delayed collagen synthesis etc)
Psychological impact of wounds because stress/self concept plays a large role in adaptive mechanisms
What is the nursing process for skin integrity?
assessment: skin is subject to change over time. Have normal baseline
skin: ongoing assessment occurs to guard against skin breakdown
risk assessment: the braden scale used to rate the pressure injury (lower the number on scale, greater the risk)
what is granulation tissue?
red, moist tissue composed of new blood vessels (indicates progression toward healing)
what is slough?
soft yellow or white tissue (stringy substance attached to wound bed which needs to be removed in order to heal)
what is eschar?
black or brown necrotic tissue which usually needs to be removed before healing can proceed
what is wound exudate?
describes the amount, colour, consistency, and odour of wound drainage and is apart of wound assessment. Excessive exudate usually indicates presence of an infection
what are the two types of tissues?
- wounds with loss of tissue (secondary intention): burn/pressure injury where wound is left open until fills with scar tissue
- wounds without loss of tissue (primary intention): clean surgical incision, edges are closed and infection risk is low
what is stage 2 of a pressure injury?
the sore digs deeper past the top layer of skin and your skin is broken. It looks like a puss-filled blister
what is stage 3 of a pressure injury?
the sore has gone through to the fat tissue. puss, heat, sometimes odour. Black anywhere meaning tissue has died.