Pressure Injury & Wounds Flashcards
What is a pressure injury?
Wound resulting from pressure or friction. Skin may be intact and erythemic or skin may be nonintact with open areas. (skin not intact/injury may be superficial/very deep)
How does a patient get a pressure ulcer?
-Occurs when external pressure is exerted on soft tissue (bony prominences) for long periods of time.
What part of the body can develop pressure injuries?
sacrum, buttocks, greater trochanters, elbow, heels, ankles, occiput and scapulae
What is Stage 1 of a pressure injury?
Over bony prominences that will not blanch or turn white when gently touched.
Area may feel warm, firm, soft or boggy.
Pts may report burning/tingling of site. (can be prevented)
What is a Stage 2 pressure injury?
Partial thickness loss and exposed dermis.
Serum filled blisters, broken blisters that reveal a shallow, pink or red ulceration that is moist.
Subcutaneous tissue not visible. (harder to heal/infection possible)
Not a result of adhesive skin injury, incontinence or traumatic wound.
What is a Stage 3 pressure injury?
Full thickness loss involving damage to the epidermis, dermis & subcutaneous tissue but doesn’t involve muscle/bone. May be infected, produce drainage, and take longer to heal than stage 1 & 2. (Rolled wound edges are present at this stage)
What is a Stage 4 pressure injury?
full thickness skin & tissue loss; involves deep tissue, necrosis of muscle, fascia, tendon, joint capsule & sometimes bone. (infection can involve deeper tissues such as bone (osteomyelitis) Extremely slow to completely heal & depends on the pts health status
What an is an unstageable ulcer?
Full thickness tissue loss/ impossible to accurately stage because of Eschar. Eschar is hard dry dead tissue, should never be removed if it completely covers site to help protect the damage tissue underneath. (If eschar comes off will reveal stage 3-4 pressure injury).
what is a deep tissue injury?
Red, maroon or purple color and does not blanch.
May form blood blister or thin blister that overlies a dark wound bed, the blister will break and reveal a thin layer of eschar underneath.
(Prolonged pressure/shear force)
Medical device- related pressure injury & Mucosal membrane pressure injury
What are the effect on nutrition & wound healing?
Lack of calories and adequate protein impairs tissue growth.
Deficiency in intake of vitamin A, C and zinc in diet
Inadequate fluid intake causes the wound to be dry.
What is Primary Intention Healing?
wound is clean with little tissue loss (surgical incisions.) Edges are approximated/wound is sutured, glued, stapled, or stitched closed. (helps prevent germs and healing process to occur quickly)
what is secondary healing?
greater tissue loss/wound edges are irregular; edges cannot be brought together. (pressure injury or traumatic wound) Left open to gradually heal with wide scar. Must be packed with moist gauze to absorb drainage and allow tissue to grow (STERILE TECHNIQUE)
What is tertiary healing?
(delayed primary closure healing): wound is left open for a time to allow granulation to occur then its sutured closed. (drainage wound)
