Pressure Injuries Flashcards
Who is at the greatest risk of developing pressure injuries?
SCI patients
Hospitalized patients
long term care pts
How does pressure lead to cell death?
pressure reduces blood flow which causes ischemia which increases metabolic waste and acidosis leading to cell death
What extrinsic factors cause pressure injuries?
- amount and duration of pressure
- friction/shear
- moisture and temperature
What intrinsic factors cause pressure injuries?
- muscle atrophy
- medications
- malnutrition
- medical conditions
- advanced age
What is a stage 1 pressure injury?
non-blanchable erythema that is localized and typically over a bony prominence (difficult to see in dark pigmented pts.)
What is a stage 2 pressure injury?
partial thickness skin loss with exposed dermis
- red or pink wound w/o slough or granulation tissue
- usually moist
- not a skin tear, dermatitis, or maceration
What is a stage 3 pressure injury?
full thickness skin loss with visible adipose
- slough may be present
- undermining, tracts, and epibole possible
What is a stage 4 pressure injury?
full thickness skin and tissue loss with exposed named tissues and may have eschar or slough and common undermining
What is a deep tissue pressure injury?
-localized area of discolored intact or non-intact skin that is a deep purple or maroon color which indicates damage of underlying soft tissues
What tools can you use to evaluate pressure injuries objectively?
Bates-Jensen Wound Assessment Tool (BWAT) (15 items and higher the number the more severe)
Pressure Ulcer Scale for Healing (PUSH)
How should you treat a pressure wound?
- Cleanse the wound and periwound (use anti-septics if infection is suspected or confirmed but only short term)
- debride if it is needed/appropriate and there is no dry eschar and vascular supply is adequate
- dress the wound
