Pressure Injury

Presser injury

It is define as a localised injury toskin and/ or underlying tissue usually over a bony prominence, as a result of pressure, shear and / or friction, or a combination of these factors.

Classification of a pressure injury  

Stage 1 –

·         intact skin with non blanchable redness

·         colour may different from the surrounding area

·         may be painful, firm, soft, warmer or cooler

Stage 2-

·         partial thickness loss of dermis presenting as  a shallow, open wound with a red pink wound bed , with out slough

·         intact or open / serum filled blister.

·         Preaent as shiny or dry, shallow ulcer with out slogh or bruising

Stage 3

·         full thickness tissue loss, subcutaneous fat may be visible bur bone, tendon or muscle are not exposed .

·         Slough may present

Stage 4

·         Full thickness tissue loss with exposed bone, tendon or muscle

·         Slough or Eschar ( a dry scab formed on skin) may present on some parts of the wound bed.

·         Can be extended into muscle and supporting structures such as  tendon, or joint capsule.

·         Exposed bone ot tendon is visible or directly palpable

Prevention Pressure injury

·         Maintain skin integrity

·         Nutrational interventions as required

·         Alternative pressure redistribution support surface

·         Assistance with repositioning as required

·         Patient education

Written by : Suman , Bachelor of Nursing  , Australian Catholic University