Week 8 - Pressure Care Flashcards
What is a pressure injury?
- Associated with a bony prominence
- Result of prolonged pressing in sitting/lying down
Pressure injury classification
Stage 1: non-blanchable erythema of intact skin
Stage 2: partial thickness skin loss
- Stage 3: full thickness skill loss
- Stage 4: full thickness tissue loss
What causes a pressure injury?
- Intensity and duration of pressure
- Tolerance of the skill and support structures for pressure
Where do pressure injuries occur?
- Back of head
- Shoulder blade
- Lower back
- Elbow
- Heel
- Ear
- Hip
- Between ankles
How long does it take a stage 2 pressure injury to heal?
Time for improvement
- 7-14 days
Time to heal
- 14-21 days
How long does it take a stage 3/4 pressure injury to heal?
Time for improvement
- 14-28 days
Time to heal
- 140-150 days
How long does it take deep, infected wounds to heal? (Pressure injuries)
Time to heal
- 5-6 months
Long term impact of pressure injuries
- Loss of job, spouse, independence, health
Who is at risk of developing a pressure injury?
- Most people in hospitals
-
Postural observations important in managing pressure
- Upright pelvis (ASIS & PSIS are near level; ischial tuberosities breaing load)
- Posterior pelvic tilt (PSIS lower than ASIS)
- Pelvic obliquity (ASIS, PSIS & IT higher on one side
Red flags for pressure injuries
- Limited movement + sensation + muscle wasting
- Asymmetrical posture and pelvic obliquity
- Cognitive impairment & limited communication
Key factors we can influence
- Pressure
- Shear
- Friction
- Moisture
- Temperature
- Nutrition
Managing pressure
- Aim in to increase immersion into support surface
e. g.: - Cushions
- Matresses
What is PEACCT
- Posture: adopted in sitting position and in bed; how to change posture and relieve pressure
- Equipment: wheelchair, shower commode - all items need to be checked
- Activities: such as prolonged computer use
- Clothing: no thick seams
- Continence: exposure to urine and faecal matter
- Transfers: review all transfers
