pressure injuries Flashcards
pressure injuries risk
prolonged pressure, long term use of nasal cannula, face mask
bed sores (resulting from bony promises: areas that are bony: lower back, buttocks: sacrum and coccis), heels, ankles, hip bones, elbows
are common for pressure injuries.
bedridden clients who are imobile, sedated, intubated, etc..
incontinent clients (wet bed): wet skin leads to skin broke down
poor nutrition: low protein, poor fluid intake.
diabetic neuropathy: lack of sensation, lack of skin perfusion (causing foot ulcers)
liver cirrhosis (poor albumin: protein that attacks fluids). causes edema
stage 1 pressure ulcer
skin is intact, epidermis is affected but not damage, it is just red and painful.
non-blanchable, redness (erythema) (does not turn white/black when press down, it stays red), if it turns white/black when press down, its not a stage 1 injury yet.
blanchable means at risk of developing a pressure ulcer, but no pressure ulcer yet.
stage 2 pressure ulcer
skin breaks, skin is not intact and appears visibly damage.
partial loss is damage, but fatty tissue not visible
we have open wound (superficial open ulcer or closed blister)
affects the epidermis and the dermis
top sites for pressure injuries
heels/ankles, hips
sacral area, scrotum
elbow, shoulders
inside knees (friction)
occipital area and ears*
so as a nurse, make sure patients don’t develop pressure ulcers in these areas.
stage 3
skin is damage and not intact (deep tissue injury)
full loss of skin tissue (affect epidermis, dermis, hypodermis), maroon or purple color
may see the subq (fatty tissue)
but YOU WILL NOT SEE BONES, TENDONS, LIGAMENTS, slough maybe present but you can still stage it.
wound edges can be rolled away, epible (undermining, tunneling)
THREE: tunneling. get it? stage three tunneling
stage 4
deep tissue injury, skin is visibly damage with full loss of skin tissue (full thickness loss)
WILL EXPOSE BONE, MUSCLE, TISSUES, AND LIGAMENTS (you’ll be able to see them, etc..)
unstageable pressure injury
unstageable b/c there’s slough (yellowish or tan) or eschar (brownish black) that covers a full thickness ulcer, so you can’t stage it.
you can’t stage it b/c the slough and eschar covers where you need to measure it and all
deep tissue injury
presents as purplish or blackish areas over skin that’s intact
fatty tissue is injured below, may see black blister area, it may feel heavy or spongy*
interventions pressure ulcers
head to toe assessment
document
use the Braden scale: sensory, moisture, activity, mobility, nutrition, and shear
score from 6 - 23.
9 or less means very high risk. 19 - 23 (no risk)
use barrier cream to protect that skin
dry linen, wrinkle free
turn patient every 2 hours
special air beds (if they’re at a huge risk for pressure injuries or score really low on the braden scale,..
physician may recommend for nutrition consult to promote wound healing
high calorie diet w/ all nutrients needed to promote wound healing
red pink, dark pink
which stage?
stage 2
stage 1 is redness, but not dark.
stage 3 is full thickness loss, fat may be present, no bones present
stage 4: bones present, tendons, LIGAMENTS presents
unsategeable: slough and eschar makes it not visible
petechiae is most likely to occur where?
buccal mucosa, conjunctiva of eye
I mistaken petechiae for pruritis (itching), I thought they were asking where itching is most likely to occur
palms of skin is good to assess color change
sacrum, elbow, buttocks, between hips is good to assess for pressure injuries
nail beds can assess for cyanosis, oxygen, etc..
