Pressure injury Flashcards
What is included in assessment of skin?
- Colour
- Is the skin intact (no cuts, bruising, etc)
- Temperature should be warm
- Smooth texture
- Turgor
- Moisturised/dry
What are common skin integrity problems?
- Lesions
- Pruritus
- Inflammation
- Auto immune
- Infection
- Tumours
- Hair and nails
What is pruritus?
Itchiness
How many categories of skin tears are there?
Three
What is a category one skin tear?
Skin tears without tissue loss
What is a category two skin tear?
Skin test with partial tissue loss
What is a category three skin tear?
Skin test was complete tissue loss
Assessment of skin tear
Assessment of:
Cause
Location
Duration ( when did it occur)
Dimensions
Wound Bed tissue (colour, exudate)
Type an amount of exudate
Any bleeding or haematoma
Any skin flap
Surrounding skin
Infection
Pain
Treatment of skin tears
- prevent by moisturising
- Notify and document
- Clean wound with warm sailing or water
- Approximate the skin tear
- Apply dressing
- Review and assess
What is moisture associated skin damage?
Inflammation of the skin occurring with or without erosion of secondary cutaneous infection
How does moisture associated skim damage occur?
Prolonged exposure to various sources of moisture including urine stool, perspiration wound, exudates, mucus, saliva and their contents
What is a pressure injury?
Localised injury to the skin and or underlying tissue usually over a Brony prominence as a result of pressure
What causes a pressure injury?
Impaired blood flow to the skin
How often should a patient be repositioned?
Two hourly
What position should a patient be in?
30° tilt
