Pressure Injury Flashcards
HAPI stands for:
hospital acquired pressure injury
Risk Factors For Pressure Injury Development
Age-related skin changes
Immobility
Obesity or thinness
Excessive moisture or dryness
Poor Nutrition and hydration
Medications (Corticosteroids)
Previous pressure ulcer
Medical conditions affecting blood flow (Diabetes Mellitus or PVD)
Slough
Necrotic tissue that is moist, stringy, and yellow or gray
Eschar
dermis that has become leathery or thick and
black
Undermining
An area of the ulcer beneath the skin surface
that extends under the edge of the wound.
*seen in stage 3 or 4 pressure injuries
Tunneling
Narrow extensions into the surrounding tissue from
the sides of an ulcer
Stage 1 Pressure Injury
- partial thickness
- Intact skin with non-blanchable redness of a localized area
usually over a bony prominence.
Stage 2 Pressure Injury
Partial thickness loss of skin with
exposed dermis
Stage 3 Pressure Injury
Full-thickness tissue loss.
Subcutaneous fat may be visible but bone, tendon or
muscle is not exposed.
Stage 4 Pressure Ulcer
Full-thickness skin and tissue loss with exposed
bone, ligament, tendon or muscle.
Stage 1 pressure injury
Stage 2 pressure injury
Stage 4 pressure injury
Stage 3 pressure injury
Unstageable Pressure Injury
Full thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green
or brown) and/or eschar (tan, brown or black) in
the wound bed.
Unstageable Pressure Injury
Deep Tissue Pressure Injury
A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
**DO NOT classify as stage 1
