Exam 2: Week 7, Pressure Injuries 1 Flashcards
What is the Braden scale?
A scale used to predict a patient’s risk of developing a pressure ulcer
(categories: mobility, activity, sensory perception, skin moisture, nutritional status, friction/shear)
What is the expected healing time frame for pressure ulcers? (list each timeframe by stage)
Stage 1: Within 1-3 weeks
Stage 2: Within 2-6 weeks
Stage 3/4: 8-13 weeks
List 4 ways a clinician can reposition a patient
- Turning sheet
- Trapeze bar
- Support surfaces
- Hoyer lift
(Note: avoid “dragging” a patient to reposition them)
What are the 4 factors that contribute to the development of a pressure injury/ulcer
Pressure
Friction:
- occurs when two surfaces move across one another
Shear:
- Displaces deep tissue, not superficial
- Skin stays in tact
- Leads to ischemia and necrosis
Moisture
T or F? You can only stage a stage 4 pressure injury if a bone is present
False… an ulcer with exposed bone, tendon, or ligaments would be classified as a stage 4 ulcer
90% of pressure ulcers can be prevented with interventions such as…
- Education
- Positioning
- Mobility
- Nutrition
- Incontinence management
List the Braden scale score ranges and what they indicate
<13: High risk
13-14: Moderate risk (65-90% chance of developing stage II ulcer or deeper)
15-16: Mild risk (50-60% chance of developing a stage I ulcer)
<18: At risk
(note: if a patient has major risk factors such as fever, diastolic <60, hemodynamic instability, or advanced age then it is recommended they get moved one risk category higher)
List and describe some moisture associated skin damage conditions?
Intertrigo: Inflammation in skin folds related to perspiration, friction, and bacterial/fungal bioburden
Periwound maceration: Skin breakdown from wound exudate
Incontinence Associated Dermatitis (IAD): Urine, stool, secondary cutaneous infection
T or F? Pressure can impact the vascular network by increasing interstitial fluid pressure, increasing capillary pressure, decreasing lymphatic flow, restricting blood flow and can also cause ischemia/necrosis
True
Pressure related damage depends on…
- Intensity of pressure
- Duration of pressure
- Tissue tolerance
Differentiate between hyperemia and ischemia skin breakdown
Hyperemia (too much blood flow to an area)
- Skin breaks down within 30 mins
Ischemia (too little blood flow to an area)
- Skin breakdown after 2-6hrs
Differentiate between necrosis and ulceration skin breakdown
Necrosis
- Skin breaks down after 6 hours of continuous pressure (will have gray/blue coloration)
Ulceration
- Skin breaks down within 2 weeks after necrosis, possible infection
T or F? Pressure and time have an inverse relationship when referring to pressure injury formation
True
List some intrinsic and extrinsic risk factors for developing ulcers?
Intrinsic
- Diabetes
- Smoking
- Malnutrition
- Immunosuppression
- Vascular disease
- Spinal cord injury
- Contractures
- Prolonged immobility
Extrinsic
- Lying on hard surfaces
- Poor skin hygiene
Describe deep tissue injuries (DTI)
- Purple or maroon area
- Intact skin or blood blister
- Area may be preceded by pain, temp change, texture change
Differentiate between the 4 stages of ulcers
Stage I:
- Intact skin with non-blanchable erythema (constant redness)
- Redness does not dissolve within 30 mins of pressure removal
Stage II:
- Partial thickness (into the dermis)
- Open wound, but shallow
- “3 P’s”… Pink, Partial, Painful
- Also includes blisters
Stage III:
- Full thickness (through epidermis, dermis, into subcutaneous tissue)
- Slough/necrotic tissue may be present
Stage IV:
- Full thickness (through epidermis, dermis, subcutaneous tissue
- Impacts bone, ligaments, tendons, etc.
- Slough/Eschar typically present
UNSTAGEABLE if wound bed is covered by eschar/slough
Which bed position is worst for shear forces? How can this be prevented?
Semi-Fowler’s position… put the head of the bed less than 30 degrees
How often should a patient change positions?
2 hours for a full change
15-30 minutes (offload for 1-3 minutes)
Describe group 1 mattresses/overlays
These devices are “pressure reducing” and “preventative”
Examples: Gel foam overlay, waffle overlay, pressure pad/pump
Patient Population: Those “at-risk” on the braden scale (or have stage 1 or 2 ulcer)
(Benefits: Pressure and shear reduction)
Describe group 2 specialty mattresses
These devices are “pressure relieving” and “Reactive/Active”
Can be controlled with a remote or machine (which regulates bed temp, shear, and can raise/lower the head or feet). They are also perforated (holes in it)
Examples: Low air mattress, alternating pressure mattresses
Patient Population: Multiple Stage 2 ulcers on trunk/pelvis
Describe group 3 air fluidized beds
These devices are “pressure active”
Examples: Clinitron bed, skytron air fluidized therapy bed
Patient Population: (Individuals must have all of the following)
- Multiple Stage 3 or 4 ulcers
- Entirely bed ridden
- “Group 2” mattresses did not work
Which product can you use to protect against urine incontinence?
Petroleum
