Chapter 32 Pressure Injuries Flashcards
Avoidable pressure injury
A pressure injury that develops from the improper use of the nursing process
Bony prominence
An area where the bone sticks out or projects from the flat surface of the body
Chairfast
Confined to a chair
Colonized
The presence of bacteria on the wound surface or in wound tissue; the person does not have signs and symptoms of an infection
Erythema
Redness of the skin
Eschar
Thick, leathery dead tissue that may be loose or adhered to the skin; it is often black or brown
Friction
The rubbing of one surface against another
Intact skin
Normal skin without opening or damage
Pressure injury
Localized damage to the skin and or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. Injury occurs as a result of intense and or prolonged pressure or pressure in combination with shear
Shear
When layers of the skin rub against each other; when the skin remains in place and underlying tissue move and stretch and tear underlying capillaries and blood vessels causing tissue damage
Slough
Dead tissue that is soft and often moist and appears white, yellow, green or tan; tissue may be firmly attached or loose and stringy
Unavoidable pressure injury
A pressure injury that occurs despite efforts to prevent one through proper use of the nursing process
Bedfast
Confined to a bed
Pressure injury stages
Stage 1 the skin is intact
Stage 2 partial -thickness skin loss (blister or shallow ulcer)
Stage 3 Full -Thickness skin loss (slough is dead tissue that is soft and often moist)
Stage 4 Full-Thickness skin and tissue loss with muscle, tendon, and bone exposures. (Eschar)
Unstageable Full-thickness tissue loss with the injury covered by slough and eschar
Deep Tissue Injury - purple or maroon localized area of discolored intact skin or blood filled blister.
A pressure injury is
Localized damage to the skin and underlying soft tissue
Pressure injuries are the result of
Unrelieved pressure
Which of the following contributes to the development of pressure injuries?
Shear and friction
A pressure injury can develop within
2 to 6 hours
The following are risk factors for pressure injuries except
Balanced diet
Which is the most common site for a pressure injury?
Sacrum
In a light-skinned person , the first sign of a pressure injury is
A reddened area
A person care plan includes the following. Which should you question?
Scrub and rub the skin during bathing
When positioning a person, you should position them
Using assist devices
What is the preferred position for preventing pressure injuries?
30 degrees lateral position
Besides heel and foot elevators , which are used to keep the heels and ankles off the bed?
Pillows
Person sitting in a chair should shift their position every
15 minutes
A person is sitting in a chair. The feet do not touch the floor. What should you do?
Position the feet on a foot rest
Which are not used to treat pressure injuries
Plastic draw sheets and waterproof pads
The following are sources of moisture except
Barrier ointment
You see a reddened area on the person skin. What should you do?
Tell the nurse
The nurse tells you that the person pressure injury is colonized. This means that
Bacteria are present
Inflammation of the bone and bone marrow is
Osteomyelitis
Which of the following is not a prevention measure for pressure injuries?
Massage bony areas
Which is correct for preventing or treating pressure injuries?
Make sure shoes fit properly
