Pressure Injuries Flashcards
Pressure Injuries
-bed sore or decubitis ulcer
-90% in sacrum, heel, greater troch, isch tub, lat mal
-occiput for children
-can develop in 2 hours
RKs:
-shear (pressure, shear [parallel, tear drop wound], friction [2 surfaces])
-moisture
-impaired mobility: MC
-malnutrition: 2nd most common
-impaired sensation
-age
-previous PI
Etiology:
-pressure cause blood flow to tissues to stop and causes cell death
-edema and inflammation also cause cell death
-vessel occlusion preventing healing
-medical devices, beds, wheelchairs
Pressure Injury Statistics
-80% of acute care
-95% are preventable
Pressure Injuries Periwounds
-non blanchable erythema
-mottled
-necrotic ring
-derminitis if incontinence
Norton Risk Assessment Scale
-coordination, mental status, actiivty, mobility, incontinence
-2-20
Braden Scale
-predicts pressure sore risk
-mobility, activity, sensory, moisture, nutrition, friction
-6-18
Gosnell Pressure Score Risk Assessment
-mental, continence, mobility, activity, nutrition
-more documentation
-5-20 (higher worse)
PI Prevention
-positioning
-mobility
-nutrition
-incontinence
PI Staging
Stage 1: non-blanchable erythema of intact skin
-looks dark
-1-3weeks
Stage 2: Partial Thickness Loss with Exposed Dermis
-pink/red and moist (no granulation or other tissues)
-days-weeks
Stage 3: Full thickness skin loss
-can see fat, granulation tissues
-epibole or tunnelling
-8-19weeks
Stage 4: Full thickness skin and tissue loss
-exposed fascia, muscl, tendon, bone
-8-19 weeks
Unstageable: Obscured Full Thickness
-covered by slough or eschar
Deep Tissue: Persistent Non-blanchable deep red, or purple discoloration
PI Treatment/Devices
-local wound care
-pressure decreasing decivce
Pressure-Reducing: not below 23 mmhg
Pressure Relieving: below 23
Static Support: non moving defice providing cushion
Dynamic Support: uses air to redistribute forces
