Pressure Injuries Flashcards
Where are pressure injuries generally located?
Over bony prominences
What are the characteristics of pressure wound tissue?
Varies from dark red to eschar
What are the characteristics of pain associated with pressure wounds?
Varies depending on structures involved
What are the characteristics of skin associated with pressure wounds?
Macerated, wet erythmatous
What are the characteristics of Exudate associated with pressure wounds?
Varies depending on location and presence of infection
What is the definition of Pressure ulcer?
Localized injury to skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combo with shear
How do you diagnose pressure wounds?
BY TISSUE INVOLVEMENT:
- Partial thickness
- Full thickness
- Underlying structures
BY CAUSE:
- Pressure
- Shear
- Friction
What are the stages of pressure wounds?
Stage I-IV
Unstageable
Suspected deep tissue injury
What are the characteristics of stage I pressure wounds?
Intact skin with non-blanchable redness of localized area, usually over bony prominence
Darkly pigmented skin may not have visible blanching; skin color may differ from surrounding area
Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
May be difficult to detect in individuals with dark skin tones
May indicate “at risk” persons
What are the characteristics of stage II pressure wounds?
Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough
May present as an intact or open/ruptured serum-filled blister
Presents as a shiny or dry shallow ulcer without slough or bruising
Stage II should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or denudement
What are the characteristics of stage III pressure wounds?
Full thickness tissue loss with visible subcutaneous fat (bone, tendon, or muscle are NOT exposed)
Slough may be present but does not obscure depth of tissue loss
May include tunneling or undermining
Depth varies by anatomical location. Areas with no subcutaneous fat may be shallow; areas with significant adiposity can be deep
Bone and tendons are not visible or directly palpable
What are the characteristics of stage IV pressure wounds?
Full thickness tissue loss with exposed bone, muscle, or tendon
Slough or eschar may be present on some parts of the wound bed
Often include undermining and tunneling
Depth varies by anatomical location (Areas with no subcutaneous fat may be shallow; areas with significant adiposity can be deep)
Exposed bone and tendons are visible or directly palpable
What are the characteristics of unstageable pressure wounds?
Full thickness tissue loss in which base of ulcer is covered with slough (yellow, tan, green, or brown) or eschar (tan, brown, black)
Until enough slough and eschar is removed to expose the base of the wound, the true depth, and therefore, stage cannot be determined
Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as a biological cover and should not be removed
What are the characteristics of a deep tissue injury associated with pressure wounds?
Area of discolored intact skin or a blood-filled blister due to damage to underlying tissue
Purple or maroon localized area of discolored intact skin or blood-filled blister from 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
May be difficult to detect in darker skin tones
Evolution may include a thin blister over a dark wound bed
Wound may further evolve and become a thin eschar
Evolution may be rapid, exposing additional tissue layers ever with optimal treatment
Pressure forces can cause what injuries?
Stage I
or
Deep tissue injury
