High Risk for Developing Pressure Injuries

Anandhi Sathyakumar

Director Nursing, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu

Introduction

Pressure injuries are localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices.
They result from prolonged or severe pressure with contributions from shear and friction forces.

Classification Of Pressure Injury

Risk factors contributing to Pressure Injury

Limited Mobility
Nerve damage
Age or impaired thinking
Poor nutrition
Unmanaged incontinence
Poor health and circulation

Pressure Ulcer Drivers of Risk

Areas of Body at risk

Toe
Fingers
Heel
Sacrum
Ischial tuberosity
Back of head
Shoulder
Scapula

Extrinsic Risk

Pressure
Shear
Friction

Intrinsic Risk

Reduced mobility
Sensory impairment
Level of consciousness
Extremes of age
Terminal illness
Diabetes
Prior ulceration
Malnutrition
Dehydration

How to identify individuals who are at risk of developing Pressure injury

Early Inspection means Early Detection

History collection
Visual Inspection
Using Braden scale
Skin inspection
At the time of transfer

History Collection

Since how long, you had been deceased?
Do you need assistance for daily living?
Have you ever noticed any dryness over your skin?
What is your food style and how often you eat?
Do you need assistance for mobility?
Do you sweat a lot?
How is your motion pattern?
Do you have any feeling of itching?
How often you hydrate yourself?
How is your urine output?
How often you move out of bed?

Visual Inspection

Visual inspection will be done at the areas of greatest risk on the skin. This is mandatory at the time of admission during initial assessment

Skin contact areas
Bony prominences
Braces, Stocking, O2 tubing, Bi-pap mask, Foley catheter, IV tubing , hubs and jewelry
While giving personal care
Any complaints of discomfort / pain
Check areas at risk of damage
If it is red, check for blanching
Check areas at risk of damage
Follow primary lesions , e.g., scar tissue, crusts from dried burns

Time-Assessment

TIME is a valuable acronym or clinical decision tool to provide systematic assessment and documentation of wounds. It stands for Tissue, Infection or Inflammation, Moisture balance and Edges of the wound or Epithelial advancement.
The TIME framework is a useful practical tool based on identifying the barriers to healing and implementing a plan of care to remove these barriers and promote wound healing.
The wound healing process can be divided into four separate stages: hemostasis, inflammation, proliferation, and maturation. Each of these phases is defined by its vital chemical processes, which work to maintain the individual’s well-being by regenerating their damaged cells.

Wound Management

TIME stands for Tissue, Infection/Inflammation, Moisture balance, and Edge of wound – representing the four key aspects of wound bed preparation that need to be systematically assessed and addressed to optimize wound healing

Braden Scale

Note: Patients score 16 or less are considered to be at risk of developing pressure injury 15 or 16 – Low risk; 13 or 14 – Moderate risk; 12 or less – High risk

Skin Inspection at the Time of Transfer

As visual inspection, the skin inspection must be done while transfer out and while receiving in the patient/interdepartmental transfer. This enhances the patient safety through documentation

Skin Assessment Techniques

Color
Temperature
Turgor
Lesion
Edema

Why the pressure injuries prevention protocols are failing?

Lack of Risk assessment performed on Admission
Lack of Risk assessment performed on transfers to any Department
e.; ICU, Ward, OT, Day care
Lack of protocols for prevention of pressure ulcer in ICU and ward
Lack of awareness of guideline and under reported
Implementation issues of protocol
Insufficient training
Issues with continuum of care

High Risk for Developing Pressure Injuries

High Risk for Developing Pressure Injuries

Anandhi Sathyakumar

Nightingale Journals