Week 2 Pressure Injuries Flashcards
whoa re the greatest people at risk for pressure injuries
SCI, hospitalized, and long term care patients
what causes pressure injuries
pressure! so pathophysiology and intrinsic and extrinsic factors
if you increase pressure… your. intracapillary BP…
you increase intracapillary BP and decrease blood flow to soft tissue and obstructed lymph vessels.
the decreased flow to soft tissue causes
ischemia
if you have increased metabolic waste and acidosis you get
cell death
capillary permeability and local edema increases which limits
circulation and leads to necrosis
if you decrease fibrinolysis, you get fibrin deposits which leads to
micro thrombi with occludes vessels and leads to more necrosis
extrinsic factors that cause PI
amount of pressure duration friction shear moisture temperature
intrinsic facts that cause PI
muscle atrophy, impaired mobility, medications, malnutrition, medical conditions (like impaired semsationand previous pressure ulcers), advanced age
locations of PI in supine
posterior heel, sacrum coccyx, SP, medial humeral epicondyle, scapula, occiput
locations of the PI in prone
anterior tibia and knee and iliac crest
location in S/L
malleoli, medial and lateral femoral condyles, greater trochanter, lateral humeral epicondyle, ear
W/C location
sacrum and coccyx and ischial tuberosity and greater trochanter
what is stage I
non- blanchable erythema, and localized over a bony prominence and difficult to detect with darker skin
what is stage II
partial thickness skin loss with exposed dermis (pink or red wound without slough or granulation tissue)moist.
Stage 2 is not
skin tears
dermatitis
maceration
Stage 3
full thickness skin loss with adipose exposed and slough may be present. There is undermining, tracts and epibole possible.
Stage 4
full thickness skin and tissue loss with exposed bone, tendon or muscle, and may have slough or eschar and undermining and tracts
unstageable
may have dark eschar or slough or a combo of both. It is obscured full thickness skin and tissue loss because the base is covered with eschar or slough and true depth can’t be determined
what is a DTI
deep pressure injury that is localized area of discoloration with intact or non-intact skin. It is purple or maroon in color, and there is damage to underlying tissue. it is difficult to detect with darker skin tones. THE WOUND HASNT OPENED YET
