Pressure Injuries Flashcards
what is a Stage I pressure injury?
what are the signs/symptoms of a Stage I pressure injury?
- warm skin temperature
- tissue consistency (firm or boggy feel)
- sensation (pain/itching)
- persistent redness (light skin) or persistent red, blue, or purple hues (dark skin
what is a Stage II pressure injury?
partial thickness loss with exposed dermis
presents as a shallow, open wound with a viable, moist, pink or red wound bed, without slough.
may also present as an intact or open/ruptured serum-filled blister
what are the 3 P’s of a Stage II pressure injury?
Pink
Partial
Painful
what is a Stage III pressure injury?
full thickness tissue loss
involving epidermis, dermis, and subcutaneous tissue
what is a Stage IV pressure injury?
full thickness tissue loss with exposed bone, tendon, or muscle
what is a Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled blister
Damage of underlying soft tissue from pressure and/or shear.
Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
what is an Unstageable pressure injury?
Full-thickness tissue loss in which the base of the wound is covered by slough
what is a Stage I pressure injury?
pressure related alteration of intact skin with localized area of non-blanchable redness, usually over a bony prominence
how to prevent pressure injuries?
- remove the pressure on bony prominences
- use specialized support surface (mattresses, cushions, etc)
- early intervention
- patient family/caregiver education/involvement
- good skin care program
- minimize friction
- positioning
how to position patients for pressure injuries?
- head of bed < 30 degrees
- pillows
- reposition every 2 hours in bed
- reposition every 20min in chair
- off loading
