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Advanced MNT 1 > Pressure Injuries > Flashcards

Pressure Injuries Flashcards

1
Q

Pressure Injuries
- pressure ulcer, decubitus ulcer, bed sore

Localized damage to the skin and/or underlying tissue usually over a ____ prominence, as a result of pressure or pressure in combination with _________

A

bony
shear and/or friction

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2
Q

The tolerance of soft tissue for pressure and shear may also be affected by the ________, _________, _________, and ________.

A

microclimate
nutrition
perfusion comorbidities
condition of the soft tissue

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3
Q

Pressure injuries are among the most common conditions encountered in patients ___________ or requiring __________ care

Estimated 2.5 million pressure injury cases/year in the U.S

A

acutely hospitalized
long-term institutional

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4
Q

Ischemic ulcers/injuries

unrelieved pressure occludes __________ resulting in an inadequate supply of __________ to the ________ and __________

A

capillary blood flow
oxygen & nutrients
epithelium
supportive tissue

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5
Q

Common sites => _________________________

A

sacrum, heels, hips, greater trochanters, ankles, elbow, shoulder, back of the head, inner knees

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6
Q

Primary Risk factors for pressure injuries

A

unrelieved pressure over bony prominences
friction and shearing forces
moisture
immobility

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7
Q

Secondary risk factors for pressure injuries

A

malnutrition
body weight
fever
infection
anemia
vascular changes
neurological changes
decreased sensation
incontinence
iatrogenic factors

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8
Q

Shear is a ___________ that causes a __________ to move across the _____ as the _____ is held in place

Internal body structures and skin tissues moving in opposite directions leading to:
___________ and __________

A

horizontal force
bony prominence
tissue
skin

Friction between the skin and surface
Shear strain deep within the tissue

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9
Q

Guidelines provided by the _____________ for stages

A

National Pressure Injury Advisory Panel (NPIAP)

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10
Q

Stages of Pressure injuries

A

Stage 1
Stage 2
Stage 3
Stage 4
Unstageable Pressure Injury
Deep Tissue Pressure Injury

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11
Q

Tissue layers from surface inward

A

Epidermis
Dermis
Adipose Tissue
Muscle
Bone

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12
Q

Stage 1 Pressure Injury

_____ skin with __________ of a localized area

May be difficult to detect in those with _______

Area may be _____ and ______ compared to adjacent tissue

A

Intact
non-blanchable redness

darker skin tones

painful
warm

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13
Q

Stage 2 Pressure Injury

________ with ________

Presents as a _________ ulcer with a _______ and ________

The wound bed is ______, ______, and may also present as

A

Partial-thickness skin loss
exposed dermis

shallow, open
red-pink wound bed
without slough

viable
moist
an intact or ruptured serum-filled blister

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14
Q

Stage 3 Pressure Injury

_________ skin loss involving __________

________ may be visible but __________ are not exposed

Presents as a ______
_________ may be visible

A

Full-thickness
damage to or necrosis of subcutaneous tissue

Subcutaneous fat
bone, tendon, & muscle

deep crater
Slough and/or eschar

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15
Q

Stage 4 Pressure Injury

_________ skin loss with exposed ____________(4)

_____ or _____ may be present

______, ______, and ______ often occur

Can extend into _____, _____, and ______

Can result in _________

A

Full thickness
muscle, tendon, ligaments, or bone

Slough or eschar

Epibole, undermining, and tunneling

muscle, tendons, & joint capsule

osteomyelitis

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16
Q

Unstageable Pressure Injury

_____________ loss in which the actual depth of the ulcer and extent of tissue damage is ______________ in wound bed

The true depth, and therefore stage, cannot be determined until the ____________ but will then be either a ________

A

full-thickness skin and tissue
obscured by slough &/or eschar

slough &/or eschar are removed
Stage 3 or 4

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17
Q

Deep Tissue Pressure Injury

Persistent _________ injury with ___________ discoloration due to intense &/or prolonged pressure and shear forces at the bone-muscle interface

A

non-blanchable deep
red, maroon, or purple

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18
Q

Complications from Pressure Injuries

Pain
Infection: ______, _______, _______, and _______

Associated with _________, ___________, __________, and ______

A

abscess
cellulitis
bacteremia
osteomyelitis

decreased QOL
prolonged hospital stay
increased health care costs
increased mortality

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19
Q

All patients should be screened on admission to any health care agency and periodically reassessed using the

“________________”:

Examines: sensory perception, moisture, activity, mobility, nutrition status, friction/shear
Score of < 12 indicates high risk for developing pressure injuries
For those determined to be at risk=> Daily skin assessment

A

Braden Scale for Predicting Pressure Sore Risk

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20
Q

The Braden Scale for Predicting Pressure Sore Risk examines __________, ________, _______, ______, _________, ________

score of ____ indicated high risk for developing pressure injuries
for those at high risk, they should get ____________

A

sensory perception, moisture, activity, mobility, nutrition status, friction/shear

≤12

daily skin assessment

21
Q

Relieve or redistribute pressure:

Bed-bound persons: Turn & reposition at least once every ______

Chair-bound persons: Reposition every ______

Persons who are able should shift weight every ________

A

2 hours
hour
15 minutes

22
Q

other than moving the patient, ______, ____________ and ___________ can help

A

Pressure-relieving mattresses

Pillows & foam wedges under or between bony prominences

Increase activity/movement (e.g., wheelchair push-ups)

23
Q

Avoid friction & shearing by using
________ and Maintain _________ (if appropriate with medical condition) for those on bed rest

A

Lifting devices
HOB <30-degree angle

24
Q

Skin care:
Keep skin clean
Avoid _______
_________ for incontinence
Adequate _______
Maintain/replete nutritional stores

A

excessive moisture
Bowel & bladder programs
hydration

25
Q

treatment and management
- Interdisciplinary approach
- Improve tissue perfusion by eliminating pressure
- Wound ___________
- Debridement of _________
- Monitoring for and treatment of _______
- Operative repair: ____________and________
- MNT

A

cleansing & dressing
necrotic tissue
infections
debridement, skin grafts

26
Q

Evaluation of healing or lack of healing:

_____________ Tool (Pressure Ulcer Scale for Healing) can be used for evaluation of healing

A

National Pressure Injury Advisory Panel’s PUSH

27
Q

Factors that Interfere with Wound Healing

Malnutrition
Infection
Ischemia
Smoking
Diseases/conditions: __________
Medications: __________

A

atherosclerosis, CHF, ischemia
obesity, immunologic deficiencies, diabetes/hyperglycemia

immunosuppressant drugs
corticosteroids

28
Q

Appetite
Current weight & weight history: underweight, obese, ________
Adequacy of total nutrient intake: _______
Current medical status and PMHx
Medications
Functional status: __________
Chewing/swallowing
GI status

A

unintentional weight loss
current & PTA
Ability to eat independently

29
Q

Nutrition-Focused Physical Examination:
_______
________
________ which involves ______, ______, and ______

A

Muscle wasting

Vitamin or mineral deficiencies

Wound Analysis
- Number of pressure injuries
- Staging & size
- Drainage (fluid & protein losses)

30
Q

Laboratory Assessment
____________=> hydration status
________=>________ can delay wound healing

A

Serum Na, BUN, Osm

Glucose
hyperglycemia

31
Q

Wound healing requires energy for _____, _____, and _______
Underfeeding impairs wound healing

ENERGY: Provide ________ with a pressure injury who are malnourished or at risk for malnutrition

Individualize based on medical conditions and level of activity
May need to adjust kcal to promote weight gain or loss

A

synthesis of collagen
cell metabolism
angiogenesis

30-35 kcal/kg

32
Q

Sufficient protein needed for ________, _________, and ________
Protein can be lost in __________ and __________
Protein deficiency delays wound healing
Goal is to provide adequate protein for positive nitrogen balance

A

cell synthesis
collagen & connective tissue formation
immune function

wound exudate & drainage

33
Q

PROTEIN:

Provide __________ for adults with a pressure injury who are malnourished or at risk of malnutrition

Patients should consume ________ of high-quality protein at each meal to increase protein synthesis

A

1.25-1.5 g protein/kg

25-30 g

34
Q

_______ is a conditionally essential amino acid during periods of acute metabolic stress and injury

A

arginine

35
Q

Arginine promotes the transport of ________ into tissue cells

Can enhance wound ______ and ________

Stimulates the release of ________ and ___________ which can improve wound healing

A

amino acids

strength
collagen deposition

growth hormone
insulin-like growth factor 1

36
Q

Arginine may promote wound _______, improve __________, enhance _________

Clear and definitive guidelines for its safe & effective use?

A

repair
nitrogen balance
immune function

have yet to be established

37
Q

Adequate fluid intake is needed for good ________ and _______ of healthy tissue and wounds

Monitor for signs of dehydration
Commonly used formula: _______ or _______

A

perfusion
oxygenation

~30 ml/kg or 1 ml fluid/kcal

38
Q

Provide additional fluid for those with:

A

Heavily draining wounds
Fever
Dehydration
Vomiting or diarrhea
High protein intake may require additional fluids

39
Q

Deficiencies in _____, _____ and ______ can inhibit wound healing

A

vitamin C
zinc
copper

40
Q

Encourage a balanced diet to include good sources of vitamins & minerals

Provide/encourage vitamin & mineral supplementation only when _______________

A

dietary intake is poor or deficiencies are confirmed or suspected

41
Q

vitamin C Aids in ________
Also required for ___________ formation and stimulation of ________ activity

Vitamin C deficiency has been associated with delayed wound healing, increased risk of wound infection and dehiscence

A

collagen synthesis
capillary & fibroblast
neutrophil

42
Q

Is vitamin C stored in body?

At risk=>
individuals with _________
the ______,
________ individuals,
_______,
individuals who eat no _______

A

no

alcohol use disorder
elderly
severely injured
smokers
fruits or vegetables

43
Q

In non-deficient individuals, vitamin C ___________

If deficient:
Recommend ______ for ______

If renal failure, avoid supplementation of _______ due to the risk of renal ______ formation

A

has not been proven to enhance wound healing

100 mg TID
1 month

> 200 mg/d
oxalate stone

44
Q

ZINC Required for:
______________ synthesis
_________ synthesis
___________________

A

Protein & DNA
Collagen
Cell replication & growth

45
Q

Zinc deficiency can result in _________ and ____________

Individuals at risk for deficiency=> ______, ______, _____, and ______

A

delayed wound healing
impaired immune function

diarrhea
malabsorption
metabolic stress
elderly

46
Q

Lack of studies showing significant benefit of Zn supplementation on pressure injury healing in the absence of _______

For deficiency, the optimal supplemental dose is ________
If clinical signs of Zn deficiency are present provide:
________ for _______

Doses ________ may inhibit ________ by interfering with _______

Often provided as ______ of which _____ is elemental zinc

A

Zn deficiency

unknown
25-40 mg/d of elemental Zn daily for 10 days

> 50 mg/d
wound healing
copper absorption

zinc sulfate
23%

47
Q

MNT FOR PRESSURE INJURIES

Provide high _____ and high ________ foods or
_____________________

If needed and consistent with patient wishes, use of ___________ with _____________ formulas

A

kcal
protein fortified
oral nutrition supplements between meals

supplemental tube feedings
high protein, nutritionally complete

48
Q

Recommendation from the International Guideline on the Prevention and Treatment of Pressure Ulcers/Injuries:

Provide high-calorie, high-protein, ________, _____ and ________
ONS (oral nutrition supplement)

or _______ for adults with a ______ or greater pressure injury who are malnourished or at risk of malnutrition.

A

high-calorie

arginine
zinc

enteral formula
Stage 2

49
Q
A

Advanced MNT 1 (20 decks)

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