Chapter 36 Pressure injuries Flashcards
Bony prominence
an area where the bone sticks out or projects from the flat surface of the body
pressure point
Intact skin
Normal skin and skin layers without damage or breaks
Pressure injury
localized damage to the skin and underlying soft tissue, the injury is usually over a bony prominence or related to a medical or other device and results from pressure or pressure combination with shear
Shear
when layers of the skin rub against each other, when the skin remains in place and underlying tissues move and stretch
Ulcer
A shallow or deep crater-like sore of the skin or mucous membrane
Supine position pressure points
-back of head
- shoulder blades
- elbows
- sacrum
- heels
Lateral position pressure points
- side of head
- ear
- shoulder
- hip
-greater trochanter
-thigh - knees
- leg
- ankle
- heel
Prone position pressure points
- cheek and ear
- shoulder
- breast
- elbows
- ribs
- hip bones
- genitalia
- thighs
- knees
- toes
Fowlers position
- back of head
- shoulders
- sacrum
- lower hip bones
- heels
- toes
sitting position pressure points
- shoulders
- sacrum
- hips
- lower hip bones
- feet
Blanchable
when pressure is applied to the skin, blood is pressed away. Skin turned white and then returns to normal color
Non-blanchable
the skin doesn’t become white or pale when pressure is applied
Slough
dead tissue that is shed from the skin it is usually light colored, soft, and most
Eschar
is thick, leatherly dead tissue that may be loose or adhered to the skin. Black or brown in color
Stage 1 pressure injury
Non-blanchable erythema of intact skin
Skin is intact and has reddened
Step 2 pressure injury
Partial-thickness skin loss with exposed dermis
Wound is pink or red and moist. May involve a broken or intact blister. Fat and deeper tissues are not visible
Stage 3 pressure injury
Full-thickness skin loss
Skin is gone. Fat can be seen in the ulcer. Slough, eschar or both may occur
Stage 4 pressure injury
Full-thickness skin and tissue loss
Skin is gone. Muscle, tendon, ligament, cartilage or bone is exposed. Slough, eschar or both may be present
Unstageable pressure injury
Obscured full-thickness skin and tissue loss
Skin and tissue loss. The extent of tissue damage cannot be seen because of slough or eschar. When slough is removed, injury can be seen
Deep tissue pressure injury
Persistent non-blanchable deep red, marron, or purple discoloration
Intact or non-intact skin is deep red, maroon, or purple and remains non-blanchable. The wound is dark or is a blood-filled blister
Reposition bedfast persons at least
1 - 2 hours
Reposition chairfast persons every
15 minutes
Bed cradle
a metal frame placed on the bed and over the person.
Top linens are brought over the cradle to prevent pressure on legs, feet, toes
Heel elevators
raise the heels and feet off the bed
Elbow and heel protectors
are made of foam padding, pressure-relieving gel, sheepskin or other cushioning materials.
They fit the shape of elbows and heels
Gel or fluid filled pads and cushions
have pressure-relieving gel or fluid. Used for chairs and wheelchairs
Special beds
Some have air flowing through the mattress
