2. INTRODUCTION
• Pressure injury is a serious problem in bedridden and
critically ill patients.
• Overall prevalence was found 7.8% in India and prevalence
was 24.3% among ICU patients.
• Pressure injury extends the hospital stay of a patient by an
average of 13 days whereas eighty percentage of pressure
injury are preventable with conscientious assessment and
appropriate interventions by nurses
3. DEFINITION
• The term “pressure injury” replaces “pressure ulcer” in
the National Pressure Ulcer Advisory Panel (2016).
4. • A pressure injury is localized damage to the skin and/or
underlying soft tissue usually over a bony prominence or
related to a medical or other device. The injury can present
as intact skin or an open ulcer and may be painful. The
injury occurs as a result of intense and/or prolonged
pressure or pressure in combination with shear. The
tolerance of soft tissue for pressure and shear may also be
affected by microclimate, nutrition, perfusion, co-
morbidities and condition of the soft tissue.
6. LAYERS OF SKIN
• The skin is the largest organ of the body. The skin compromised three
major layers.
• Epidermis- Outermost layer of the skin composed mostly of dead skin
cells.
• Dermis- The second layer has sweat glands, oil glands, nerve endings
and small blood vessels called capillaries. The nerve endings in this
layer transmit sensations of pain, itch, touch and pleasure. Hair
follicles also originate in this layer.
• Subcutaneous adipose tissue- is the deepest layer of the skin and is a
layer of fat and collagen. This layer is important in controlling the
temperature of the skin.
7. VARIATION IN SKIN SEEN IN PRESSURE INJURY
• Epithelium- Epithelial tissue often appears
lighter than surrounding tissue (i.e. light pink
in color).
• Epithelialization occurs when the epidermis
regenerates over a wound surface.
• Basal keratinocytes travel from the wound
edges, where they multiply until they meet in
the middle.
• It is extremely vulnerable to damage from
friction, shearing and pressure.
(Keratinocytes – is predominant cell type in
epidermis)
8. • Eschar (Necrotic tissue)-Eschar is
composed of necrotic granulation tissue,
muscle, fat, tendon or skin.
• The term stable eschar is used to describe
leathery, dry hard eschar tissue, such as the
eschar that commonly forms on the heels
or other bony prominences.
• The term unstable eschar is used to
describe tissue that is undergoing a
softening process caused by proteolytic
enzyme production from bacteria present in
the tissues.
• This type of eschar is characterized by pain,
redness, purulent discharge, warmth and
edema.
9. • Slough- A stringy mass that may or may not
be firmly attached to surrounding tissue.
• Slough color may range from white (scant
bacterial colonization) to yellow or green
(larger bacterial counts) to brown
(hemoglobin is present).
• Slough may become thicker and harder to
remove the longer it is present.
• Slough is indicative of full-thickness stage 3
pressure injury or stage 4 pressure injury.
10. • Granulation tissues- The formation
of granulation tissue is thought to be
an intermediate step in the healing
process of full-thickness wounds.
Granulation tissue is also very fragile
and prone to easy injury.
• Granulation tissue is shiny red and
granular in appearance when it is
healthy.
• Granulation tissues may appear pale
in color when inadequate blood flow
exists.
11. • Epibole- are the edges that
are rolled or curled indicate
a chronic wound.
• In which epithelial cells are
unable to adhere to a moist,
healthy wound bed and
can't migrate across and
resurface the wound.
15. COMMON PRESSURE INJURY SITES
• In supine position
• Back of the head
• Shoulder, elbow
• Buttocks, heels
• In lateral position
• Ear, shoulder
• Elbow, hip, thigh
• Leg, heel
• In prone position
• Face, elbow, rib cage
• Thigh
• Knees, toes
16. • In semi-fowler
position
• Back of head
• Shoulder, base of
spine, buttocks
• Heel, toes
• In sitting position
• Shoulder blades, spine,
elbow
• Sacrum, ischial
tuberosity (buttocks)
• Heels
17. RISK FACTOR FOR PRESSURE INJURY
• Immobility or limited mobility/ altered level of consciousness
• Bowel & Bladder Incontinence
• Shearing and friction injuries
• Advanced age
• Malnutrition or debility
• Obesity
• Dehydration
• Contractures
• Use of orthotic devises or restraints
• Use of diapers / excess skin moisture
18. PREVENTION OF PRESSURE INJURY
1. Risk Assessment
• Assess all at-risk patients at the time of admission, at regular
intervals thereafter and with a change in condition.
• Consider all bed-bound and chair-bound persons, or those
whose ability to reposition is impaired, to be at risk for
pressure injury.
• Use a valid, reliable and appropriate method of risk
assessment that ensures systematic evaluation of individual
risk factors for e.g.- Braden scale and document all the care
given to the pressure injury patient.
19. SCALES USED IN ASSESSMENT OF RISK FOR
PRESSURE INJURY.
• There are several scales available for assessment of risk for
pressure injury. Some of the
• most commonly used scales are
• Norton scale- Norton scale uses the five criteria i.e. physical
condition, mental state, activity, mobility and incontinence
to assess the risk for pressure injury.
• Waterlow scale- The score was the criteria, which includes:
build/ weight for height, skin type, sex, age and malnutrition
screening tool and continence mobility.
20. BRADEN SCALE:
• The Braden scale assesses a patient's risk of developing a
pressure ulcer by examining six criteria
• Sensory perception- It Is the ability to respond meaningfully to
pressure related discomfort.
• Moisture- It is degree to which the skin is exposed to moisture
• Activity- It is the degree of physical activity.
• Mobility- It is the ability to change and control body positions.
• Nutrition- It is the usual food intake pattern of patient.
• Friction and shear- It is the amount of assistance a client needs
to move and the degree of sliding.
21. • Each category of Braden scale is rated on a scale from 1 to 4
excluding the “friction and shear” category which is rated on
a 1t o 3 scale. The total score is 23. The higher score implies
the lower risk of developing the pressure injury and vice
versa.
Risk Total score
Very high risk 9 or less
High risk 10-12
Moderate risk 13-14
Mild risk 15-18
No risk 19-23
23. Interventions for preventing pressure injury based on
risk assessment using Braden scale
Very high risk:
• Skin assessment and inspection every shift, pay attention to
heels.
• Elevate heels. Use pillows between knee and bony
prominence.
• Consider specialty mattress or alpha beds/ripple bed.
• Don’t elevate head of bed more than 30 degree.
• Turn and reposition patient every 2 hourly.
• Consider physiotherapist consult.
24. Continue..
• Use moisture barrier ointment. Avoid soap and hot water.
• Check incontinence pads frequently (q 2-3 hourly) or as
needed.
• Offer nutrition supplements. Record dietary intake and I & O
• If patient NPO > 24 hr. discuss plan with physician.
• Keep bed linen clean, dry and wrinkle free.
25. High risk:
• Skin assessment and inspection every shift. Turn patient
every 2 hr.
• Teach and do small frequent shifts of body weight.
• Use comfort devices. Consider use of alpha beds.
• Small frequent meals. Offer nutrition supplements.
• Avoid massaging pressure points.
• Keep linen dry, clean and wrinkle free.
26. Moderate risk:
• Skin assessment and inspection in every shift. Turn patient
every 2hr.
• Elevate heels, use heel protector.
• Teach small frequent shifts of body weight.
• Provide structured mobility plan.
• Monitor nutritional intake and record intake and output.
• Keep bed linen clean and dry.
27. Mild risk:
• Daily skin inspection, turn patient every 2 hr.
• Encourage patient to report pain over bony prominence.
• Encourage ambulation.
• Keep bed linen clean and dry.
No risk:
• Daily skin inspection. Encourage ambulation.
• Turn and reposition every 2 hr.
• Keep skin moisturized.
• Out of bed for all the meals. Provide food choices.
28. 2. Care of back
• Back care means cleaning and massaging back, paying
special attention to pressure points. Especially back massage
provides comfort and relaxes the client, thereby it facilitates
the physical stimulation to the skin, the emotional relaxation
and improve the circulation of back.
Procedure-
• Perform hand hygiene.
• Assemble all equipment required.
• Check the client's identification and condition.
• Explain to the client about the purpose and the
procedure.
29. • Close all windows and doors, and put the curtain for warmth
and privacy.
• Placing patient in the appropriate position:
• Move the client near you.
• Place mackintosh covered by big towel under the client's
body.
• Expose the client's back fully and observe it whether if there
are any abnormalities. If you find out some redness, heat or
sores, don’t give any massage to that place. If the client has
already some red sore or broken-down area, report to the
senior staff or doctor.
30. •Lather soap by sponge towel. Wipe with soap and
rinse with plain warm water. To make clean the
back before we give massage with oil/ lotion.
•Put some lotion or oil into your palm. Apply the oil
or the lotion and massage the back by using all the
movement like effleurage, kneading, friction and
tapotement for at least 3-5 minutes by placing the
palms:
• from sacral region to neck
• from upper shoulder to the lowest parts of buttocks
31. • Applying too much may bring irritation and
discomfort.
• Help for the client to put on the clothes and return
the client to comfortable position.
• Replace all equipment in proper place.
• Perform hand hygiene.
• Document on the chart with your signature, including
date, time and the skin condition. Report any
findings to senior staff.
32. 3. Care of Pressure points:
• Assess pressure points every day. Look for the change in skin
color.
• Use support surface on beds and chairs to reduce pressure.
• Use of comfort devices to prevent pressure from bony
prominence or to provide comfort to the patient.
• Support pressure points with pillows to allow pressure
points to Suspend above the mattress or use pillows, pads or
other available comfort devices.
• Promote use of air mattress beds (alpha beds) to prevent
pressure injury.
33. Continue..
• Do not use ring or donut-shaped devices. (The edges of
these devices create areas of high pressure that may
damage tissue.)
• Use heel protector devices. Heel protector devices offload
pressure from the heels
• Chair cushions should be provided for a chair bound
person
• Place pillow under one hip at a time if patient cannot
tolerate full turning.
• Do not massage or vigorously rub skin that is at risk of
pressure injury.
34. •Prevent pressure injury due to medical devices for
e.g.-oxygen tubing, catheters, casts etc. Inspect the
skin under and around medical devices at least twice
daily for the signs of pressure related injury on the
surrounding tissue.
•Do not leave the individual on a bedpan longer than
necessary
•Lubricate or powder bedpans prior to placing under
the patient. Roll patients to place the bedpan rather
than pushing and pulling it in and out.
36. 4. Repositioning Techniques
• Patients On bed
• Turn patient every 2 hourly. Avoid lying postures that
increase pressure, such as the 90° side-lying position, or
the semi recumbent position.
• Limit head-of-bed elevation to 30° for an individual on
bedrest unless contraindicated (Studies have shown
that elevated head of bed puts more pressure on sacral
area of patients and it increases the chances of having
Pressure Injury).
37. • Reposition the individual in such a way that pressure is
relieved or redistributed (pressure redistribution surface
reduces tissue interface pressure below capillary closing
pressure).
• Avoid positioning the individual on bony prominences with
existing non-blanchable erythema.
• Record repositioning regimes, specifying frequency and
position adopted. Turning schedule should be written and
placed at the bedside.
38. •Patients on chair
• Reposition chair bound person every hourly.
• Select a seated posture that is acceptable for the
individual and minimizes the pressures.
• Ensure that the feet are properly supported either
directly on the floor, on a footstool, or on footrests
when sitting (upright) in a bedside chair or wheelchair.
• Avoid the use of elevating leg rests if the individual has
inadequate hamstring length.
39. 5.Manage Moisture:
• Assess and address the cause of moisture (e.g.-
diaphoresis, incontinence) because skin macerated from
moisture tears more easily.
• Assess for any type of incontinence – urinary/fecal,
implement toileting schedule. Check for incontinence
every two hourly or as needed.
• Keep the skin clean and dry. Avoid use of hot water and
soap it may dry the skin and increases the chances of
having pressure injury.
40. Continue.
• Use skin moisturizer/lotions to hydrate dry skin in order to
reduce risk of skin damage.
• Try to reduce and eliminate incontinent episodes with
proper bladder training or promote use of under pads to
absorb moisture.
• Change diaper frequently (whenever soiled) or keep the
diaper open for some time.
41. 6. Maximal Remobilization:
• Passive range of motion
exercises for bedridden
patients.
• Consult with physiotherapist
to plan appropriate
measures for patient.
• Bony prominences should
not have direct contact with
one another.
42. 7 Microclimate control
• Consider the need for additional features such as ability to
control moisture and temperature when selecting a
support surface.
• The temperature of intensive care units must be
maintained between 18.5 – 21 degrees Celsius. As the
temperature increases the relative humidity of
environment decrease that can lead to dryness of skin.
Ideal humidity level should be maintained between 50%
to 60%.
• Consider the need for moisture and temperature control
when selecting a support surface cover.
43. 8. Manage Nutrition/hydration:
• Assess the adequacy of total nutrient intake (i.e., food,
fluid, oral supplements and enteral/parenteral feeds).
• Provide 30 to 35 calories/kg body weight for adults at risk
of a pressure injury who are assessed as being at risk of
malnutrition.
• Offer 1.25 to 1.5 grams protein/kg body weight daily for
adults at risk of a pressure ulcer or with existing pressure
injury or who are assessed to be at risk of malnutrition, and
reassess as condition changes.
44. Continue.
• Provide high calorie, high protein oral nutritional
supplements between meals if nutritional requirements
cannot be achieved by dietary intake.
• Consider enteral or parenteral nutritional support when
oral intake is inadequate.
45. • Assess renal function to ensure that high levels of protein
are appropriate for the individual.
• Provide and encourage adequate daily fluid intake for
hydration for an individual assessed to be at risk of or with
a pressure injury.
• Monitor individuals for signs and symptoms of dehydration
including change in weight, skin turgor, urine output,
elevated serum sodium, and/or calculated serum
osmolality.
46. 9. Reduce Friction and Shear:
• Avoid dragging the person across the bed sheets. Either lift the
person by using a lift sheet or have the person use an overhead
trapeze to briefly raise their body because friction can occur
when moving the patient in the bed.
• Keep the bed free from crumbs and other particles that can rub
and irritate the skin.
• Do not raise head of bed more than 30 degree. (Studies have
shown that elevated head of bed puts more pressure on sacral
area of patients and it increases the chances of having Pressure
Injury.)
47. Continue..
• Wash the person gently. Avoid rubbing or scrubbing the
skin and make sure they are thoroughly dry.
• Take care of pressure injury scars because they can break
down faster than unwounded skin.
• Transparent dressings and hydrocolloid dressings (e.g.,
Duoderm, Restore) protects against the effects of friction.
48. STAGING AND MANAGEMENT OF PRESSURE INJURY
• Stage 1 Pressure Injury: Non blanchable erythema of intact
skin
• Intact skin with a localized area of non-blanchable erythema,
the skin appears red on lighter skin color and it may appear
differently in darkly pigmented skin.
• Presence of blanchable erythema or changes in sensation,
temperature, or firmness may precede visual changes.
• Color changes do not include purple or maroon
discoloration; these may indicate deep tissue pressure injury.
The skin may be painful, but it has no breaks or tears.
49.
50. Erythema
superficial reddening of the skin,
usually in patches, as a result of injury
or irritation causing dilatation of the
blood capillaries.
• Blanching erythema-
Erythema disappears on finger
pressure
• Non-blanching erythema- it is
defined area of redness that does
not blanch (become pale) under
applied light pressure.)
51. Management of stage I
• Inspect the skin for additional damage each time the
individual is turned or repositioned while in bed.
• Protect skin from moisture. Manage incontinence Use
moisture barrier creams.
• Use transparent film, hydrocolloid dressings or skin
sealants
• Don’t massage the bony prominences and relieve
pressure from bony prominences.
52. Continue.
• Do not turn the individual onto a body surface that is
damaged or still reddened from a previous episode of
pressure loading, especially if the area of redness does not
blanch.
• Pad between skin-to-skin contact, or skin-to-equipment
contact that may rub together.
53. • Off load area of pressure ulcer
with pressure reducing
distribution surface with
turning and repositioning
frequently. Reduce friction and
shear while repositioning
• Friction- Friction is the
mechanical force exerted when
skin is dragged across a coarse
surface.
• Shear-combination of friction
and gravity. Occurs when one
layer of tissue slides over the
other
54. Hydrocolloid dressing
• Hydrocolloid dressing is an opaque
or transparent dressing for
wounds.
• A hydrocolloid dressing
is biodegradable, non-breathable,
and adheres to the skin.
• Transparent film dressings are clear
so you can see the wound through
them. This type of dressing is used
to protect skin in pressure spots.
55. Stage 2 Pressure Injury: Partial-thickness skin loss
with exposed dermis
• Partial-thickness loss of skin with exposed dermis.
• The wound is viable, pink or red, moist, and may also present
as an intact or ruptured serum-filled blister. adipose (fat) is
not visible and deeper tissues are not visible. granulation
tissue, slough and eschar are not present.
• The skin breaks open, wears away, or forms an ulcer, which is
usually tender and very painful because nerve endings are
exposed.
56. Continue.
• These injuries commonly result from adverse microclimate
(i.e. Increased skin temperature and moisture at the
skin/mattress interface) and shear (mechanical force that
acts on an area of skin in a direction parallel to the body's
surface) in the skin over the pelvis and shear in the heel.
• This stage should not be used to describe moisture
associated skin damage including incontinence associated
dermatitis, intertriginous dermatitis, medical adhesive
related skin injury, or traumatic wounds (skin tears, burns,
abrasions).
57.
58. Management of stage II
Dry Wound
• Cleanse with normal saline, apply small amount of antibiotic
cream like Mupirocin or cover with non-adherent dressing (
Allevyn dressing). Change dressing every day.
• Frequent assessment and dressing should be done as per the
wound healing stage.
• Off load area of pressure ulcer with pressure reducing /
distribution surfaces with turning and repositioning every 2
hourly.
59. • Minimal Drainage
• Cleanse with normal saline, apply non-adherent
(Allevyn dressing) and prevent soiling or dislodging.
Monitor placement every day.
• Pain relief measures should be implemented.
60. Pain management of patient with pressure injury.
1. Assessment
•Assess the pain.
•Pain is generally categorized
into four categories.
•Background pain/basal
pain- related to underlying
cause of wound.
•Breakthrough pain-
incident pain due to
mobilization, dressing
slippage etc.
61. Continue.
• Procedural pain- result from routine interventions
such as dressing removal, cleaning or dressing
application.
• Operative pain- associated with any intervention.
• Identify the cause of pain, nature of pain and intensity
of pain by using pain assessment scale.
• When assessing wound pain be specific to pain type,
duration of pain, intensity of pain and impact of pain.
62. Pharmacological management
• A non-opioid (NSAID) analgesics with or without analgesics
adjuvant.
• If the pain is not controlled opioids may be used eg;- morphine
• For procedural and operative pain topical opioids analgesics or
local anesthesia e.g. Lignocaine.
Non-pharmacological management
• Position off the pressure injury.
• Prevent friction and shear during repositioning.
• Use of pressure redistribution devices.
• Assist in addressing pain including relaxation techniques,
guided imagery, music therapy etc.
63. Care or Management of wound:
• Identify the patient, Assess the stage of wound wash hands
properly.
• Assess pain by using a pain scale. Manage the pain by local
or general anesthesia as prescribed by physician.
• Put on gown, gloves etc. as necessary.
• Open the sterile tray. Spread the sterile towel around the
wound.
• Pick up the dissecting forceps and remove the dressing and
put it into the paper bag.
64. • Note the type and amount of drainage present.
• Ask the assistant nurse to pour small amount of normal
saline into the bowl.
• Clean the Pressure wound from the center to periphery
discarding the used swabs after each stroke
65. • After thoroughly cleaning of the wound, dry the wound with
dry swabs using the same precautions. Discard the forceps in
the bowl.
• Apply medications if ordered for e.g.- antibiotic (Mupirocin )
• Apply the dressing.
• In case of contaminated won't move from least contaminated
area to most contaminated area. Use Clean Gauze For every
wipe.
66. • Don’t close or cover contaminated and infected wound but
leave them open to heal. Injudicious closure of a
contaminated wound will promote infection and delay
healing.
• Remove the gloves discard it into the bowl.
• Documentation of the procedure with date, time, signature
including the amount of drainage and type of wound.
67. PUSH TOOL
• PUSH tool is used to monitor the change in the pressure ulcer
status over time.
• PUSH tool is a tracking tool that allows nurses to calculate
and monitor the rate of healing for each wound. It categorizes
the ulcer into Length×Width (surface area), exudate and type
of wound.
• Then three is sub score for each of these characteristics. Add
the sub scores to obtain the total score or PUSH score.
68. Continue.
• Comparison of total score measured overtime provides an
indication of the improvement or deterioration in pressure
ulcer healing.
• If scores go up the wound is deteriorating, if score goes
down the wound is healing. Changes in the score over time
provide an indication of the changing status of wound.
69. Stage 3 Pressure Injury: Full-thickness skin loss
• Here adipose (fat) is visible in the ulcer and
granulation tissue and epibole are often present.
slough and/or eschar may be visible.
• The depth of tissue damage varies by anatomical
location; areas of significant adiposity can develop
deep wounds.
70. • Undermining and tunneling may occur. Fascia (a band
or sheet of connective tissue, primarily collagen,
beneath the skin that attaches, stabilizes, encloses,
and separates muscles and other internal organs),
muscle, tendon, ligament, cartilage and/or bone are
not exposed.
• If slough or eschar obscures the extent of tissue loss
this is an unstageable pressure injury.
71.
72. Management of stage III
• Cleanse with normal saline using aseptic techniques, cover with
non-adherent dressing change dressing every day.
• Off load area of pressure ulcer with pressure relieving /
distribution surface with turning and repositioning frequently.
• Slough 30% or less in the wound, negative pressure wound
therapy is preferred treatment.
• Meticulous wound care as prescribed. (photo therapy/ electrical
stimulation/ hyperbaric oxygen therapy etc.)
• Debridement may require.
73. Debridement
• Debridement is the medical removal of dead, damaged or
infected tissue done by physician/ surgeon to improve
healing potential of remaining healthy tissue.
Indications
• Any abscess formation.
• Ulcer cover with dead and necrotic tissue.
• It promotes the growth of healthy granulation tissue.
74. TYPES
• The main type of wound debridement is
Sharp debridement
• Surgical removal of necrosis
Mechanical
• Use of mechanical force to remove necrotic tissue
Chemical or enzymatic
• Performed with help of Chemicals or Direct exposure of enzyme.
Autolytic
• Involve use of synthetic coverage on wand to promote healing
75. Stage 4 Pressure Injury: Full-thickness skin and
tissue loss
• In stage 4 full-thickness skin and tissue loss with exposed or
directly palpable fascia, muscle, tendon, ligament, cartilage
or bone in the ulcer. slough and/or eschar may be visible.
Epibole undermining and/or tunneling often occur.
• Undermining- Undermining generally includes a wider area
of tissue than tunneling. Tunneling generally occurs in one
direction, whereas undermining may occur in one or more
directions.
76. Continue.
• Depth varies by anatomical location.
• If slough or eschar obscures the extent of tissue loss this is
an unstageable pressure injury.
• Stage 4 may have little or no pain due to significant tissue
damage.
77.
78. Management of stage IV
• Cleanse with normal saline, cover with non-adherent
dressing (Allevyn dressing) change dressing every day.
• Presence of Slough with drainage. Sharp debridement /
Enzymatic debridement
• Use dressing for moderate to copious drainage management.
• Slough 30% or less in the wound, negative pressure wound
therapy is preferred treatment.
• The wound should be closed with tunneling and
undermining shall be filled appropriately.
79. Continue.
• Negative pressure wound therapy- Negative-pressure
wound therapy is a therapeutic technique using a vacuum
dressing to promote healing in acute or chronic wounds. It is
done by using a sealed wound dressing connected to a
vacuum pump.)
80. Allevyn dressing-
• These are the absorbent foam
dressing.
• They Provides an effective
barrier function to exogenous
bacteria as well as help to
maintain an optimal balance in
fluid creating a moist wound
environment for healing.
81. Unstageable Pressure Injury: Obscured full-
thickness skin and tissue loss
• Full-thickness skin and tissue loss in which the extent of
tissue damage within the ulcer cannot be confirmed because
it is obscured by slough or eschar.
• If slough or eschar is removed, a stage 3 or stage 4 pressure
injury will be revealed. stable eschar (i.e. dry, adherent,
intact without erythema or fluctuance) on the heel or
ischemic limb should not be softened or removed.
(fluctuance-collection of pus under skin)
82.
83. Management of unstageable pressure injury.
• Cleanse with normal saline, cover with non-adherent
dressing change dressing every day.
• Use dressing for drainage management.
• Sharp or enzymatic debridement for the management
of slough.
84. Deep Tissue Pressure Injury: Persistent non-
blanchable deep red, maroon or purple discoloration
• 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.
• Pain and temperature change often precede skin color
changes. discoloration may appear differently in darkly
pigmented skin.
85. Continue.
• This injury results from intense and/or prolonged pressure
and shear forces at the bone-muscle interface.
• The wound may evolve rapidly to reveal the actual extent of
tissue injury, or may resolve without tissue loss.
• If necrotic tissue, subcutaneous tissue, granulation tissue,
fascia, muscle or other underlying structures are visible, this
indicates a full thickness pressure injury.
86.
87. Documentation and reporting
• Documentation and reporting are needed for continuity of care. it is
also a legal requirement showing the nursing care performed or not
performed by nurse.
• Perform at thorough Skin inspection at the time of admission or
transfer. Assess skin and documentation in nursing notes about Risk
assessment, redness of skin or presence of pressure injury.
• In every shift do the risk assessment for pressure injury using Braden
scale and clearly document the stage of pressure injury, site of
pressure injury, number of pressure injuries, status of wound,
documentation of status of wound in PUSH tool chart and care given
to the patient. Put time and signature.
88. Continue..
• Transfer and receive the patient with documentation of
details of pressure injury.
• Identify and document the risk of developing pressure injury
in patient.
• Report any new abnormality, stage and status of pressure
injury to team leader/ in charge/ physician.
Effective documentation and report keeping underpins service
delivery by nurse and provide a record of quality of care
delivered.
Notas del editor
Slough can range in color from white (scant bacterial colonization) to yellow or green (larger bacterial counts) to brown (hemoglobin is present).
