PI Basics
Name three common pressure injury sites
Ears, Sacrum, Heels, Buttocks, Mucous Membranes, Hips, Knees
Name the tool utilised to assess a person's risk of pressure injury development
Waterlow Assessment
Name the tool utilised when a patient is deemed 'at risk' of pressure injury development
PIPMP - Pressure Injury Prevention & Management Plan
Name two people in the hospital you could talk to if you were unsure on how to manage a PI
CNE, wound nurse, OT
Are bones and tendons visible or directly palpable in a Stage 3 Pressure Injury?
No - bone, muscle & tendon visibility is a characteristic of Stage 4 Pressure Injury
Name two medical devices that can cause pressure injuries
Oxygen delivery devices, catheter tubing, NG tubing, ID bracelets, casts
Name five factors that increase a person's risk for PI development
age, malnourishment, incontinence, neurological deficits, decreased mobility, smoking, organ failure, anaemia, surgery
What angle should the head of bed & knee bend be for reduced pressure over high-risk areas?
30 degrees
How often should a patient with a known pressure injury have a skin assessment?
Daily
Describe what classifies a Stage 1 Pressure Injury
intact skin with non-blanchable erythema of a localised area, usually over a bony prominence
How do pressure injuries occur?
Prolonged contact between tissue and a hard surface (bony prominence, medical devices), repeated shear or friction resulting in localised tissue trauma
Name three causes of tissue malnourishment
smoking, anaemia, peripheral vascular disease, organ failure, terminal cachexia
How would you proceed with a patient identified as 'at risk' of PI development who can mobilise with x1A, but declines to mobilise?
address any controllable factors (pain, equipment, fear), educate patient on importance of mobilising/SOOBIC, allied health referrals/advice, prepare to implement appropriate management strategies if patient continues to decline mobilising, document conversation
Name two resources that can provide information & education about pressure injury prevention & management
HETI/MHL, OT, wound nurse, CEC
Describe what classifies a Stage 2 Pressure Injury
partial thickness skin loss, red wound base, nil slough
Describe the pathophysiology of pressure injury development
prolonged contact -> tissue deprived of oxygen & nutrients -> tissue ischaemia -> tissue injury -> tissue necrosis
Name two types of medications that can increase a person's risk of pressure injury development
cytotoxics, long term steroids, high dose steroids, anti-inflammatories
Name five appropriate pressure injury prevention strategies
repositioning schedule, proactive toileting, pressure offloading, education, pain management, correctly fit medical devices, prophylactic dressings, equipment (roho, air mattress), encourage adequate nutrition & hydration, skin protection & moisture balance, OT referral
What strategies would you put in place for a patient with a hospital-acquired Stage 2 Pressure Injury?
offload area (equipment, repositioning), analgesia, dress wound, wound nurse referral, IIMS
Describe what classifies an Unstageable Pressure Injury
full thickness tissue loss, where the base of the wound is covered with slough and/or eschar. the injury cannot be staged until enough slough or eschar is removed to expose the wound bed