Pressure Injury Flashcards
Exam 1
Cause of pressure injury
Skin and underlying soft tissue are compressed b/w a bony prominence and external surface
What is the result of a pressure injury?
reduced tissue perfusion & gas exchange –> cell death
Name at least 3 risk factors for Pressure Injury
(1) lack of mobility
(2) exposure of skin to excessive moisture
(3) undernourishment
(4) aging skin
(5) cognitive decline or impairment
(6) peripheral vascular disease
(7) diabetes mellitus
Name at least 3 complications that can come from pressure injury.
(1) increased morbidity
(2) increased healthcare costs
(3) sepsis
(4) kidney failure
(5) infectious arthritis
(6) osteomyelitis
When surfaces rub the skin and irritate or tear fragile epithelial tissue
Friction
When the skin itself is stationary and the tissues below the skin shift or move
Shearing forces
Name at least 3 ways to improve pressure tolerance.
(1) Preserve skin integrity
(2) Clean the skin
(3) Moisturize
(4) Wash skin
(5) Do NOT massage reddened areas
(6) Perineal care every 2 hours
(7) Keep skin-to-skin areas dry
nonblanchable erythema of intact skin
Stage 1 PI
partial-thickness loss with exposed dermis
Stage 2 PI
full-thickness skin loss
Stage 3 PI
full-thickness loss of skin and tissue
Stage 4 PI
obscured full-thickness skin and tissue loss
Unstageable
persistent nonblanchable deep red, maroon, or purple discoloration
Suspected deep-tissue injury
“hidden” wounds that extend from the primary wound into surrounding tissues
Tunneling
What does blanching indicate?
Adequate tissue perfusion.
inflammation of the skin and subQ tissue extending beyond the area of injury
Cellulitis
necrotic tissue that appears like a layer of black, gray, or brown collagen; may be dry and leathery, or full of exudate and yellow / tan in appearance
Eschar
may be pale pink to beefy red
Granulation tissue
separation of the skin layers at the wound margins from the underlying granulation tissue
Undermining
Name the 2 priority problems for PI
(1) Compromised tissue integrity
(2) Potential for infection
Mechanical entrapment and detachment of dead tissues
Mechanical debridement
Topical enzyme preparations to loosen necrotic tissue
Topical chemical debridement
Promoting self-digestion of dead tissues by naturally occurring bacterial enzymes
Natural chemical debridement
Surgical removal of excessive exudate and loose debris
Sharp debridement
What types of wounds are unlikely to have successful grafting (surgery)?
Wounds with poor blood flow
Name 3 key changes to report when monitoring for infection
(1) Sudden deterioration of the wound + increase in size/depth
(2) Change in color or texture
(3) Change in quantity, color, or odor of exudate
