Patients at high risk for stress injury with a score of 13-14 need to be evaluated every three days, and a score of ≤9 needs to be evaluated every shift.
Details:
Pressure injury refers to a localized injury to the skin and cartilaginous tissues that occurs in the body between the forces of two objects in contact. It is mainly characterized by a surface-to-surface approach, initially manifesting as erythema of the intact skin, which may then develop into small blisters or epidermal loss, especially in the area under pressure. There are many causes of pressure injuries, including vertical pressure, friction and shear, and medical device-related pressure injuries.
1, vertical pressure injury: mostly seen in long-term supine position of the patient, stationary vertical continuous pressure can affect the blood supply of the pressure area, resulting in venous return obstacles, so that some people appear local edema, further aggravate the risk of oxygen supply of the skin? Usually occurs in the occipital roughness, scapula, elbow, sacrococcygeal and heel, pressure damage from deep to shallow;
2, friction and shear damage: friction is the epidermis to cause damage, the skin is damaged to the external invasion of the defense is reduced, easy to be attacked by external factors, and then the formation of ulcers. The vertical direction of gravity and the horizontal direction of force can make the relative deformation between the tissues, resulting in shear force. Shear force compared to the vertical direction of the pressure is more harmful, shear force will cut off a large area of blood supply, pressure damage is deeper;
3, medical device-related pressure injury: the cause of the injury is mainly for the use of diagnostic or therapeutic medical devices used to lead to pressure injuries, the shape of the injury site is often the same as the shape of the medical device. Due to the anatomical characteristics of this type of injury tissue, this type of injury can not be staged.
Deep Tissue Injury Stage:
Deep Tissue Injury Stage is a potential soft tissue injury by pressure or shear, the skin locally becomes purple or brownish-purple, and the epidermis or shows congestion.
This part of the tissue may have been previously painful, firm, tender, moist, or hot or cold in comparison to neighboring tissues, whereas in dark-skinned patients it is more difficult to detect deep-tissue injuries, and the evolution of the injury may begin with a small blister on a dark black wound, and the injury may shift rapidly to expose subcutaneous tissues even with the appropriate treatment for pressure ulcers in this stage.