Pressure Injuries (Ulcers) Nursing | Patho, Causes, 6 Stages, Braden Scale

Summary

This video covers pressure injuries, formerly called pressure ulcers, highlighting their causes, risk factors, common sites, and stages. It explains that immobility, incontinence, poor nutrition, diabetic neuropathy, and low albumin levels increase skin breakdown risk, especially over bony prominences like the sacrum, heels, and hips. The six stages of pressure injuries are detailed, including stage 1 (red, intact skin) through stage 4 (full-thickness loss) and unstageable wounds with eschar or slough. Prevention strategies include regular repositioning, proper nutrition and hydration, skin assessment, and monitoring with the Braden Scale. Practical NCLEX tips for documentation, teaching, and wound care are also emphasized.

Takeaways

• 🛏️ Pressure injuries, formerly called pressure ulcers, are caused by prolonged pressure on bony prominences or medical devices.
• 📌 The most common areas for pressure injuries are the sacrum/coccyx, heels/ankles, and hip bones, with shoulders and elbows also at risk.
• ⚠️ Risk factors include immobility, incontinence, poor nutrition, diabetic neuropathy, and low albumin from liver disease.
• 1️⃣ Stage 1 pressure injury affects only the epidermis and is non-blanchable red skin.
• 2️⃣ Stage 2 involves the epidermis and dermis, presenting as an open wound that is red or pink and shiny or dry.
• 3️⃣ Stage 3 extends into subcutaneous fat, may include tunneling, and involves full-thickness skin loss.
• 4️⃣ Stage 4 is the most severe, affecting muscle, bone, or tendon.
• 🖤 Unstageable pressure injuries have full-thickness skin loss with eschar (black/brown) or slough (yellow/stringy), hiding the wound bed.
• 💜 Deep tissue injuries appear dark purple with damage below intact skin, less commonly tested but important to recognize.
• 🔄 Prevention and treatment include regular repositioning every 1–2 hours, adequate protein and fluid intake, wound care, and risk monitoring using the Braden Scale.
• 📸 Full skin assessment with documentation and photos should be done within the first 24 hours of admission to prevent hospital liability.
• 💧 Adequate hydration is critical, with urine output ≥30 mL/hr, and albumin levels between 3.5–5.0 g/dL to support tissue health and wound healing.

Q & A

What are pressure injuries, and what is their main cause?

Pressure injuries, formerly called pressure ulcers, are caused by damage to the skin or underlying tissues, usually over bony prominences, often due to prolonged pressure. This commonly occurs in bedridden patients who are not repositioned regularly or from medical devices like oxygen masks.

What are the top three most common areas for pressure injuries?

The most common areas for pressure injuries are the lower back and buttocks (including sacrum and coccyx), heels and ankles, and hipbones. The shoulder area, such as the scapula and elbows, is also at risk.

What are some common risk factors for developing pressure injuries?

Key risk factors for pressure injuries include being bedridden, having incontinence, poor nutrition (low protein or fluid intake), diabetic neuropathy, and liver cirrhosis, which can all contribute to skin breakdown.

How does incontinence contribute to pressure injuries?

Incontinence leads to wet skin, which weakens the skin barrier and makes it more susceptible to breakdown, increasing the risk of developing pressure injuries.

What is the significance of albumin levels in preventing pressure injuries?

Albumin, a protein in the blood, helps attract fluid back into the vascular spaces. Low albumin levels, as seen in liver cirrhosis, can lead to edema (fluid buildup), increasing the risk of skin breakdown and pressure injuries.

What are the six stages of pressure injuries?

The six stages of pressure injuries are: Stage 1 (red, intact skin), Stage 2 (open wound, epidermis and dermis affected), Stage 3 (full-thickness skin loss into subcutaneous tissue), Stage 4 (involvement of muscle, bone, or tendon), Unstageable (wound obscured by necrotic tissue), and Deep Tissue Injury (purple or maroon skin indicating deep tissue damage).

How is a Stage 1 pressure injury identified?

A Stage 1 pressure injury is characterized by red, intact skin that does not blanch (turn white when pressed), affecting only the epidermis, the outermost skin layer.

What are the key signs of an unstageable pressure injury?

An unstageable pressure injury has full-thickness skin loss with the wound bed obscured by two types of necrotic tissue: eschar (black or brown, dead tissue) and slough (yellow, stringy tissue).

What is the Braden Scale, and how is it used?

The Braden Scale is a rating system used to assess the risk of pressure injury development. It is typically assessed every shift and evaluates factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

What role does nutrition play in preventing pressure injuries?

Proper nutrition, especially adequate protein and fluid intake (2-3 liters of fluid per day), is crucial in maintaining healthy skin and promoting wound healing. Urine output is a key indicator of hydration, and less than 30 mL per hour may signal inadequate fluid levels.