pressure injury Flashcards
cell adaptation to sublethal injury
- hypertrophy (cell growth)
- hyperplasia (increased cell production)
- atrophy (cell degeneration)
- metaplasia (one type of tissue is replaced by another type)
- dysplasia (abnormal development of cells)
- anaplasia (loss of specialized feature of a cell)
causes of lethal cell injury
- hypoxia/ischemia
- heat
- cold
- radiation
- electrothermal injury
- mechanical trauma
- chemical injury
- microbial injury
- neoplastic growth
apoptosis
programmed cell death
necrosis
- tissue death
- not normal in developed tissues
- serious when many cells involved
defence against cell injury
- skin and mucous membranes
- mononuclear phagocyte system
- inflammatory response
- immune system
inflammatory response
- biological response to cell injury cause by pathogens, irritants, chronic conditions
- divided into vascular response, cellular response, exudate formation, healing
inflammatory response: exudate formation
- fluid and leukocytes move from circulation to site of injury
- CM: redness, swelling, heat, malaise, tachycardia, temperature increase, chills
inflammatory response: healing process
- regeneration
- repair: primary intention (initial phase, granulation phase, maturation and scar contraction), secondary and tertiary intention
ability of cells to regenerate
- labile cells (skin, lymphoid, bone marrow, mucous membranes) divide constantly
- stable cells (liver, pancreas, kidney) retain the ability to regenerate if organ is injured
- permanent cells (CNS, cardiac) do not regenerate
wound classification
- cause (surgical/non-surgical)
- underlying pathology (vascular, pressure, diabetes)
- duration (acute, chronic)
- level of contamination
- depth of tissue
- colour
healing complications
- Adhesions
- Contractures
- Dehiscence and evisceration
- Excess granulation tissue
- Fistula formation
- Infection
- Hemorrhage
- hypertrophic scars and keloids
nursing health promotion for inflammation and healing
- prevent infection
- minimize inflammation
- adequate nutrition
nursing acute intervention for inflammation and healing
- observation and vitals
- fever
- RICE (rest, ice, compress, elevate)
- heat
- wound management: cleaning, debriding, moisture
- negative pressure therapy
- electrical stimulation
pressure injuries
localized injury to skin or underlying soft tissue as a result of excessive or prolonged pressure, shear, and tissue deformation
causes of pressure injuries
- pressure
- shearing force
- friction
- excessive moisture
pressure injuries risk factors
- diabetes
- immobility
- poor nutrition
- poor circulation
- poor hydration
- incontinence
pressure injuries CM
depends of extent of tissue involved and is stages according to deepest level of tissue damage
stage 1 pressure injuries
- lightly pigmented
- only epidermis effected
- skin intact
- non-blanchable erythema
stage 2 pressure injuries
- partial thickness skin loss involving the epidermis and dermis
stage 3 pressure injuries
- full thickness loss of skin that extends to the subcutaneous tissue
stage 4 pressure injuries
- large wound present
- muscle, tendon, or bone may be exposed
unstageable pressure injuries
- dark eschar
- slough
nursing and interprofessional management of pressure injuries
- reposition frequently
- foam mattresses
- alternating pressure mattresses
- lift sheets
- wheelchair cushions
- padded commode seats
- heel boots
