Pressure

Injuries
RLE Group 4:
Iris Khan
April Labrador
Erika Lorenzana
Blaise Lozano
JM Matados
 What is a Pressure
Pressure Injury?
injury, also called as “bed sores”, “pressure
ulcer” or “decubitus ulcer”
- These are injury to the skin and the underlying
tissue due to prolonged pressure on the skin
- Most often develop on bony areas of the body such
as:
heels, ankles, hips, and buttocks
 3 Primary Contributing Factors to
1. Pressure
Pressure Injury:
○ Constant pressure on any part of your body can
lessen the blood flow to tissues.
2. Friction
○ occurs when the skin rubs against clothing or
bedding.
3. Shear
○ occurs when two surfaces move in the opposite
 What are the Risk
factors?❏ Chronic illness (e.g.
❏ Poor blood
circulation Diabetes Mellitus)
❏ Immobility ❏ Moisture
❏ Poor nutrition ❏ Incontinence
❏ Dehydration ❏ Sensory loss
❏ Rubbing or friction❏ Changes in mental
status
Complications:
❏ Cellulitis
❏ Bone and joint infectionsCellulitis
❏ Cancer
❏ Sepsis (septicemia)
Sepsis
Stages of Pressure
Injuries
 Stage 1:
❏ Sores are not open wound.
❏ No breaks/ tears; painful
❏ Does not blanch (lose colour
briefly when you press your
finger on it and then remove
your finger).
❏ firmer/ softer and warm to
touch.
❏
❏ Tearing and wearing of the Stage 2:
Skin
❏ Formation of Ulcer
❏ Tender & Painful
❏ Extends to the deeper layer
of the skin
❏ Scrape-Like (Abrasion),
Blister-Like, Crater-Like
❏ (Sometimes) Blister may
contain clear fluid
❏ Sores are broken completely
through the top two layers of the Stage 3:
skin and into the fatty tissue
below
❏ Full thickness tissue loss
❏ may resemble a crater
❏ Tunneling and undermining

In this stage, there may be signs of

the following:
> foul odor
Stage 4: Symptoms:
At stage 4, the pressure injury
❏ Sore is deep and big
is very deep, reaching into
❏ Skin has turned black and
muscle and bone and causing
extensive damage. Damage to shows signs of infection
❏ May see tendons, muscles
deeper tissues, tendons, and
joints may occur. and bone.

These are the most serious

sores. Some may even affect
your muscles and ligaments.
 Unstageable:
❏ Full thickness tissue loss
❏ Base of the ulcer is
covered by
slough (yellow, gray,
green, tan or brown) and
/ or eschar (tan, brown or
black) in wound
bed
Suspected
Deep ❏ This is when the skin looks
like a stage 1 or stage 2
Tissue sore, but underneath the
surface it is a stage 3 or
InJury: stage 4 sore.
 Prevention
- frequently reposition patient to avoid
stress on the skin
- Maintain good nutrition and fluid
intakE
- Take good care of the skin
- Quit smoking
- Manage stress
- Exercise daily
 Management:
1. SKin Care - Clean and dry (pH
appropriate cleanser)
- Do not rub or massage the
affected skin
2. Positioning & - Application of BARRIER
Repositioning CREAM

- Employ manual handling

techniques
 MANAGEMENT
3. Surgical DEBRIDEMENT:

- Remove tissue
contaminated by bacteria,
foreign tissue, dead cells, or
crusting
- To aid in healing of very
severe burns or pressure
sores
- To get a sample of tissue for
 Management:
● Surgery that lasts longer ● Pay attention to pressure
than 2 hours has been redistribution prior to and
associated with PIs. after surgery.
● Consider the use of Gel ● In the Post-Op phase, full
Pads and Perplex boxes for integumentary assessment
complex theatre cases is required. Any altered
● Patients should be skin rigidity must be
positioned to reduce the documented on the emr
Thank You!