Integumentary system: Pressure ulcers

Pressure injuries, also known as bedsores or decubitus ulcers, are painful traumas to the skin and the underlying tissue.

Pressure injuries are usually caused by constant pressure on the skin. They could also be caused by pressure combined with friction and shearing.

Friction is when skin rubs against a surface. Shearing is when two skin surfaces rub against each other.

Pressure injuries usually appear over bony prominences, which are parts of the body with the thinnest subcutaneous tissue between the bone and the skin.

Bony prominences include the back of the head, spine, shoulder blades, elbows, sacrum, hips, knees, ankles, heels, and toes.When an individual is lying in bed or sitting for a long period of time, the skin and the subcutaneous tissue are squeezed between the bone and the surface they are lying or sitting on.

The blood vessels can become compressed, which reduces blood flow to the area. Now, if an individual is sliding down in bed, the friction and shearing damage blood vessels, which also reduces blood flow to the area.

Without the blood coming in, cells are without oxygen. This leads to cell death and tissue damage.Factors that increase clients’ risk for developing pressure injuries, include: immobility; dementia; conditions associated with poor blood flow like advanced age, heart and lung disease, and diabetes; skin conditions like thin skin related to aging, dry skin due to low water intake, or thin subcutaneous tissue due to poor nutrition; and external factors like moisture and irritants from sweat, urine, and feces.There are four stages of injury, development.

In Stage 1 the blood flow is reduced. The skin is warmer than the surrounding areas and appears red but remains intact.

When pressed on, the area doesn’t blanch or turn white. In Stage 2 only the epidermis and the dermis are affected.

It looks like a shallow open wound or a blister. In Stage 3 the damage reaches the subcutaneous tissue.

There can be drainage and slough, which is lighter-colored dead tissue. In Stage 4, the damage reaches even deeper to the muscles or bones, which become exposed.

A leathery dark layer of dead tissue called eschar can be present.If an injury is completely covered with slough or eschar, it can be difficult to see how deep the damage is.

Therefore, it is difficult to determine the stage of the ulcer. These types of injuries are referred to as unstageable injuries.

Some mechanical injuries can resemble pressure injuries. One of these is a suspected deep tissue injury.

It occurs when pressure or shearing causes damage to the muscle tissue and results in bleeding. The blood from the muscle tissue travels up to the skin.

A suspected deep tissue injury looks like purple intact skin or a blister filled with bloodThe area can also be painful or warmer or colder than the surrounding skin.

Another example is a skin tear caused by friction and shearing. In this type of injury, epidermis separates from the dermis, or both epidermis and dermis separate from the underlying tissue.

It can look like a scrape covered with skin flaps or a blister. As a nursing assistant, you should take measures to prevent the formation of pressure injuries.

One simple measure is skin care. Moisture can make the skin more susceptible to friction and shearing damage.

After bathing the client, make sure you dry their skin thoroughly. Use lotions to keep the skin soft.

Pay close attention to the areas where skin surfaces are touching, like under the breast, armpits, perineal area, and skin folds.

It is also important to prevent soiling because moisture and irritants from urine and feces can damage the skin. To prevent soiling, assist your client with their toileting needs.

If the client is incontinent, remember to check on them every hour. Take good care of their perineal area and keep the skin clean and dry.

Positioning is another important measure. If a client is unable to get out of their bed or chair, you should reposition them every 1-2 hours.

Contact between the surface they are lying on and their skin should be minimal. With the client lying on their back, place pillows under their head and neck.

Place a pillow under the back to elevate one side of the hip by 30 degrees. Place a pillow under each leg so that the heel hangs over the bed.

Alternatively, rotate the legs on one side and place a pillow between them. If the client is sitting, assist them to shift their position regularly.

You should also prevent friction and shearing. Prevent the client from sliding down in bed by lowering the head of the bed under 30 degrees.

When repositioning a client, avoid dragging or pulling them. Sometimes, you can use protective devices to reduce pressure according to the care plan.

These can be gel or foam pads that fit the entire bed or smaller ones for parts of the body like elbow pads. Mobility is another important measure.

Some clients are able to get out of their beds and chairs but prefer not to. Encourage them to get up and go for a short walk every two hours.

Lastly, promote healthy skin by encouraging good nutrition and hydration.When caring for your clients there are a few things you should report to the nurse right away.

Let the nurse know if there are any signs of pressure injuries, which include red and painful skin, skin that is warmer than the surrounding area, and redness that doesn’t fade when pressed.

Also report any changes in existing injuries, which include an increase in size or depth and signs of infection like redness, odor, or discharge.

Document the date and time of the observation.All right, as a quick recap… Pressure injuries are painful injuries to the skin and underlying tissue caused by constant pressure and pressure combined with friction or shearing.

They are more common on the skin over bony prominences. Risk factors include immobility; dementia; advanced age; heart and lung disease; diabetes; dry skin; moisture; and irritants from sweat, urine, and feces.

To prevent pressure injuries, practice proper skin care and prevent soiling; make sure that the areas where skin surfaces touch are dry; minimize the contact between the client’s skin and the surface they are lying on; reposition the client every 1-2 hours; reduce friction and shearing by lowering the head of the bed under 30 degrees; use special gel or foam pads; and have the client get up and walk every 2 hours, if possible.

If you notice any signs of pressure injuries, like pain and redness that doesn’t go away after pressure is relieved or changes in existing injuries, like an increase in size or depth, redness, odor, or discharge, inform the nurse right away.

Make sure to document the date and time of the observation.