Pressure Injuries (Ulcers)

Definition/Etiology:

• Define with pictures
• Pressure ulcer
• Suspected Deep Tissue Injury
• Shearing

Pathophysiology:

• Pressure points
• Will show picture of common pressure points

Noticing: Assessment & Recognizing Cues:

• Stage 1, Stage 2, and Stage 3 (w/pictures)
  • Stage 1-Red, not blanchable (doesn’t break skin)
  • Stage 2- Breaks skin through epidermis (see tissue)
  • Stage 3- Breaks skin through the dermis (see fat)

Interpreting: Analyzing & Planning:

• Stage 4, and other (w. pictures)
  • Stage 4- Breaks skin through fat (see muscle/bone)
• Unstageable- Cannot fully visualize
• Undermining 
• Tunneling

Responding: Patient Interventions & Taking Action:

• Prevention
  • Nutrition
  • Skin hygiene
  • Avoid skin trauma
  • Supportive devices (e.g. pillows)
  • Turning and positioning

Reflecting: Evaluating Patient Outcomes:

• Management 
  • Dressing changes
  • “Cushion” dressing
  • Wet-to-dry
  • Slough removal
• Sharp debridement
  • Necrotic tissue
• Prevent further decline

Linchpins (Key Points):

• What’s at the bottom?- that’s how bad the pressure injury is
  • Stage ½ = not broken vs. see tissue
  • Stage ¾ = see fat vs. see muscle/bone
  • Other = unstageable, undermining, tunneling
  • Prevention/ management = prevention measures & dressings