Pressure Injury Observation

Question 1

When you notice your patient has a pressure injury, what is the first step your going to do?

Answer 1

FIRST: DOCUMENT

You will document the stage, size, location, exudate, infection, pain and tissue appearance

You want your document as detailed as possible

-some facilities require pictures of the pressure ulcer in EMR, have special cameras ..

Question 2

After you have documented that your patient has a pressure ulcer, what the second step you will do?

Answer 2

SECOND STEP: WOUND CARE SPECIALIST

You will need a wound care specialist that will determine specific cleansing protocol and which types of dressings are appropriate, but these are the general principles ..

-clean with normal saline to avoid damaging cells
-keep slightly moist to encourage re-epithiallization

Question 3

After you have documented and addressed a wound care specialist, on noticing a patient who has a pressure ulcer, what is the last thing that MAY need to be done depending on the extent of the wound?

Answer 3

FINAL STEP: SURGICAL TREATMENT

Surgical treatment may need to be done if necessary

-skin grafts, skin flaps, or musculocutaneous flaps are all interventions to aid in healing