Inflammation, Wounds, and Pressure Ulcers part 6 Flashcards
What are the risk factors for pressure injuries?
- advanced age
- anemia
- contractures
- critically ill
- diabetes
- fever
- friction
- hip fracture
- immobility
- incontinence
- long or extensive surgical procedure
- low diastolic <60
- major trauma
- mental deterioration
- neurologic disorders
- pain
- peripheral vascular disease
- spinal cord injury
Damage to skin and underlying tissue occurs over a bony prominence or is related to the use of devices.
AKA: Decubitus ulcer, pressure sore, bedsore
pressure injuries
How fast can a patient get a pressure injury?
1-2 hours
- Non-blanchable erythema of intact skin
- may appear differently in darker skin
pressure injury stage 1
Partial Thickness skin loss with exposed dermis
pressure injury stage II
Wound bed visible– pink or red, moist
Fluid filled blister
Shearing injury
pressure injury stage II
Full-thickness skin loss
Pressure injury stage III
Adipose visible
Rolled wound edges
Slough/eschar may be visible (if obscures wound, unstageable)
Undermining and tunneling may occur
Pressure injury stage III
Full thickness skin AND tissue loss
Pressure injury stage IV
Exposed fascia, muscle, tendon, ligament, cartilage, or bone
Slough and/or eschar
Rolled edges, undermining and/or tunneling
Pressure injury stage IV
What causes a pressure injury to be unstageable?
because it is obscured by slough or eschar
- Persistent non-blanchable deep red, maroon or purple discoloration; may resemble a blood blister
- Prolonged pressure and sheer
Deep tissue injury
How do you assess a pt with dark skin?
- changes in color (darker, purple, brownish, bluish
- use natural or halogen light not fluorescent
- assess temp: may feel warm then cool
- feel consistency: boggy or edematous
- ask patient if itchy or painful
What are some ways to prevent pressure injuries?
- assess skin
- incontinent care
- skin moisturizer
- turn Q 2 hours bed
- trun Q 1 hour chair
- HOB 30 degrees or less
- pressure relieving devices
