What causes Pressure Injuries?

 PRESSURE ULCERS & BED SORESPressure ulcer: results when there is localized damage to the skin and underlying tissue as a result of compression between a bony area of the body and an external surface. Pressure ulcers are also known as “pressure sores” and “bed sores.”What causes Pressure Injuries?Sustained pressure - When skin and underlying tissue experience prolonged contact against a surface, the pressure may lead to insufficient oxygenation and damaged cells. This happens most often to areas that lack sufficient padding from muscle or fat, like heels, hips, shoulder blades, elbows, and the tailbone.Friction -?Friction occurs when skin is dragged across a surface. For instance, when a patient changes position or a care provider moves them. Friction is exacerbated when skin is moist.Shear - Shear occurs when two surfaces move in opposite directions; for example, when a hospital bed is elevated, a patient may slide down, pulling bones and skin in different directions.3859162537678Pressure sores can happen anywhere on your body. Highrisk areas are under constant pressure or are often moistor wet. Pressure sores are most common over bonyareas:? Tailbone? Sitting bones of the bum? Hips? Elbows? Ankles? HeelsThey are most common in patients with limited mobility such as the elderly, patients in a coma, patients with reduced pain perception, and any?patients who can’t move parts of their body. Risk Factors:Impaired functional mobility including bed mobility, transfers, ambulationAltered sensory awareness due to spinal injury, stroke or dementiaIncontinenceLimited activity – bed or chair-boundImpaired ROM, strength, balance, toneImpaired nutritional statusAltered skin integrityPainImpaired circulation4 STAGES OF PRESSURE ULCERSClassificationSymptomsWhat To DoRecoveryStage 1Mildest stageThese pressure sores only affect the upper layer of your?skin Pain, burning, or?itching. The spot may also feel different from the surrounding skin- firmer or softer, warmer or cooler.You may notice a red area on your skin. For darker skin, the discolored area may be harder to see. The spot doesn’t get lighter when you press on it, or even 10 to 30 minutes after you stop pressing. This means less?blood is getting to the area.Change patient’s position or use foam pads, pillows, or mattresses. Encourage change of laying position at least once every 2 hours. If patient is sitting, move every 15 minutes. Wash the sore with mild soap and?water?and dry it gently2-3 DaysStage 2The sore digs deeper below the surface of your skin.The skin is broken, leaves an open wound, or looks like a pus-filled? blister. The area is swollen, warm, and/or red. The sore may ooze clear fluid or pus - it’s described as painful.Follow the same steps for Stage 1. You should also clean the wound with?water?or a salt-water solution and dry it gently. This may hurt, so patient should take pain medicine 30 to 60 minutes before cleaning.Keep the sore covered with a see-through dressing or moist gauze. If you see signs of an infection (such as pus,?fever, or redness), tell the doctor.?3 days to 3 weeksStage 3These sores have gone through the second layer of skin into the fat tissue.The sore looks like a crater and may have a bad odor. It may show signs of infection: red edges, pus, odor, heat, and/or drainage. The tissue in or around the sore is black if it has died.Stage 3 sores will need more care. Talk to the doctor. They may remove any dead tissue and prescribe?antibiotics to fight infection. 1 month to 4 monthsStage 4These sores are the most serious. Some may even affect your muscles and ligaments.The sore is deep and big. Skin has turned black and shows signs of infection -- red edges, pus, odor, heat, and/or drainage. You may be able to see tendons, muscles, and bone.Tell the doctor right away. These wounds need immediate attention, such as surgery.3 months to years?Daily skin checksThe best way to spot a pressure area is to do skin checks. This should be done 2x every day. Do skin checks in the morning and at night before patient goes to bed. Payspecial attention to bony areas. Also pay attention to any skin that is red for more than 30minutes. 381952598444When examining the ulcer, look for and record the following:Location on the bodyStaging of the ulcer (See chart above!)Size of the ulcer, including depth, width, and length in centimetersPresence of undermining, tunneling, sinus tractsExudate – if present, the color and amountWound bed – appearance of the wound bed and the type of tissue visiblePresence of necrotic tissueWound edges – look carefully at the edge of the ulcer for evidence of induration, maceration, rolling edges, rednessSkin around the edges of the ulcerPresence or absence of painOdor –?if present or absentSkin checks of the vulnerable areas in “red” should be done dailyNational Pressure Injury Advisory Panel: ................
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