Med-Surg - Integumentary System, part 2: Pressure Injuries
by Cathy Parkes February 07, 2023 Updated: August 10, 2023 5 min read
Full transcript and video captions coming soon!
Hi. I'm Cathy with Level Up RN. In this video, I will be talking about pressure injuries. So many nursing textbooks still use the outdated term pressure ulcers, but, rest assured, we are talking about the same thing. This is a very important topic not only for nursing school but for your nursing practice, especially if you are going to be working in an acute care setting such as med-surg or ICU. You will see a lot of pressure injuries, and it's going to be important that you know how to stage these pressure injuries and how to care for them, so in this video, we will be talking about the pathophysiology, risk factors, staging, treatment, and nursing care of pressure injuries. And then at the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key points I'll be covering, so definitely stay tuned for that. And I will be following along with our Level Up RN Medical-Surgical Nursing Flashcards. If you have our flashcards, definitely pull those out so you can follow along with me.
A pressure injury is an injury that occurs to the skin and the underlying tissue due to prolonged or intense pressure to the area. So this typically occurs over a bony prominence, such as over the coccyx bone or over a heel, but it can also be caused by pressure from a medical device. So the pathophysiology of pressure injuries is that we have compression of tissue over that bony prominence, and this impairs blood flow to the area. This leads to inadequate perfusion and oxygenation of the cells in that area and eventually leads to cell death. Risk factors that place a patient at increased risk for pressure injuries include impaired nutrition, reduced sensation - for example, neuropathy - excess moisture, which can occur due to things like incontinence, immobility, impaired oxygenation, and friction and shear forces. So as the nurse, you always want to assess your patient for their risk of skin breakdown using a risk assessment scale such as the Norton scale or Braden Scale. So a patient who has a score of 14 or less with the Norton scale or a score of 18 or less with the Braden Scale has an increased risk for skin breakdown. And as the nurse, you're going to want to take special precautions to protect the patient's skin for breakdown, and we're going to go over those when we talk about nursing care of pressure injuries.
Let's now go over our pressure injury staging. So with a stage 1 pressure injury, we have damage to the epidermis. The skin will be intact, but we will have nonblanchable erythema. So erythema is a fancy name for redness, and when I say nonblanchable erythema, that means when I push on the area of redness, it will not blanch. It will remain red. With a stage 2 pressure injury, we have damage to the epidermis and the dermis. So at this point, we typically have an open wound with partial-thickness skin loss, and the base of the wound is usually red and moist. Alternatively, a stage 2 pressure injury may present as a serous-filled blister over a bony prominence. With a stage 3 pressure injury, damage extends to the subcutaneous tissue, so that means we have full-thickness skin loss with visible adipose tissue. So with a stage 3 pressure injury, muscle, tendon, and bone is not visible. However, we may have undermining or tunneling present. With a stage 4 pressure injury, we have full-thickness skin loss, and we do have exposed bone, tendon, or muscle, and again, like a stage 3, we may also have undermining or tunneling present.
With an unstageable pressure injury, we have necrotic tissue that is covering the wound base. So this could be slough or it could be eschar, but the wound base is covered such that we do not know the depth of the wound. So upon debridement of that necrotic tissue, then that typically reveals a stage 3 or stage 4 pressure injury, but it is unstageable until we get rid of that necrotic tissue. And just a side note. Unstageable does not mean you don't know how to stage it. I sometimes see that in the hospital with new nurses. Unstageable means it's covered in necrotic tissue. And then with a deep tissue injury, or DTI, we have damage that occurs at the bone-muscle interface. So with a DTI, we can have intact skin or nonintact skin with a purple or maroon discoloration. Alternatively, a DTI can present as a blood-filled blister as well.
In terms of treatment of pressure injuries, the first thing we want to do is remove pressure from the area. So we want to restore blood flow to the tissues there, which will enable wound healing. We can also use protective dressings over the wound, and if the wound contains necrotic tissue such as slough or eschar, then debridement may be necessary. Other therapies that are used in the treatment of pressure injuries include negative-pressure wound therapy or a wound VAC, as well as hyperbaric oxygen therapy, and skin grafts or flaps may be used in some cases as well. In terms of nursing care, we want to make sure our patient is on a specialty mattress that provides pressure redistribution. We also need to turn or reposition our patient frequently, such as every two hours. We want to make sure we keep the head of the bed under 30 degrees in order to decrease shearing forces, and we should never massage bony prominences. So that's something that may show up on a test one day, and that is definitely not the thing to do. And then we need to make sure our patient is receiving adequate nutrition. In particular, protein intake is imperative for wound healing.
All right. It's quiz time. In this particular quiz, I am going to describe a pressure injury, and you're going to give me the stage of that pressure injury. You guys ready? All right. Question number one. What stage is a pressure injury with full-thickness skin loss and visible bone? The answer is stage 4. Question number two. What stage is a pressure injury with intact skin and nonblanchable erythema? The answer is stage 1. Question number three. What stage is a pressure injury where the wound base is covered in eschar? The answer is unstageable.
Okay. I hope you did well with that quiz, and I hope you learned a lot from this video. Take care, and good luck with studying.
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