Question

A patient is lying on his right side in bed. When turning the patient, you notice reddened skin on his right trochanter. How can you determine if this is a stage I pressure injury? What are some risk factors contributing to pressure injuries?

Answer 1

Reddened skin is a sign of first stage of pressure injury or pressure sore.

PRESSURE INJURY

It is defined as the breakdown of skin integrity due to some type of unrelived pressure.usually over a bony prominence or related to a medical or other device.

HOW CAN YOU DETERMINE FIRST STAGE PRESSURE INJURY ?

• Pressure sore has begun if you remove pressure from the reddened area for 10 to 30 minutes and the skin color does not return to normal after that time.
• Test your skin with the blanching test :Press on the red ,pink or darkened area with your finger.The area should go white ,remove the pressure and the area should return to red within few seconds indicating goog blood flow.if the area stay white then blood flow has been impaired and damage has begun.
• Other sign is skin is redened,darkened and it may look hard and feel warm to the touch.

RISK FACTORS CONTRIBUTING TO PRESSURE INJURIES

• Prolonged bedd ridden patient
• same position for prolonged time
• Physical restraints : patient with spinal cord injury, poor health person
• friction of pressure area
• moisture and incontinence with bedd ridden patient : skin become prone to vulnerable with exposure to urine and stool and cause skin damage
• decreased tissue perfusion : Patient with venous insufficiency ,shock,peripheral arterial disease.
• lack of sensory perception : patient with stroke ,spinal cord injury,neuropathy
• poor nutrition and hydration
• low body mass index
• Age : at the extreme of age patient may develop pressure sore due to inablity to move or change position by themselves
• Support surfaces :The surface upon with the patient lies or sits can profoundly influence pressure over bony prominence as can lying or sitting in the same position for long periods of time.