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N104 - Aging > Week 6: Pressure Injuries > Flashcards

Week 6: Pressure Injuries Flashcards

1
Q

List some age-related changes that occur to the integumentary system?

A
  • colour and pigmentations (sunspots)
  • skin tags, keratosis (scaly spots)
  • vascularity (bruising)
  • turgor decreases
  • thickness decreases (thin & translucent appearance, wrinkles, decreased subcutaneous fat)
  • loss of moisture (dryness & flaking, decreased perspiration (sweating))
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2
Q

What are the functions of the integumentary system?

A
  • thermoregulation
  • protection of underlying structures
  • cutaneous sensations
  • stores fat
  • excretion and absorption
  • synthesis of Vitamin D
  • forms a protective barrier against chemical and micro-organisms
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3
Q

Name the largest organ in the body?

A

Skin (in terms of area and weight both)

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4
Q

A localized injury to the skin and underlying tissue, usually over a bony prominence, as a result of pressure, shear, friction, or a combination of these factors and is affected by moisture, nutrition, perfusion, and comorbidities (more than 1 disease present at the same time)

A

Pressure ulcer

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5
Q

List the process in which pressure ulcers form?

A

Pressure –> tissue compression (pushing together) –> vascular obstruction —> interference with normal cell metabolism –> cell death

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6
Q

What 4 terms indicate tissue damage?

A
  • hyperemia (normal)
  • blanched hyperemia (not concerning)
  • non-blanching (concerning as redness post hyperemia does not occur indicating blood not flowing back)
  • ischemia (lack of blood supply indicating cell death)
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7
Q

Define hyperemia:

A

localized vasodilation caused by pressure manifested by reddened skin that is a compensatory response to lack of flow to underlying tissue

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8
Q

Define blanching hyperemia:

A

return of blood flow (redness) after blanching (pressing) on a surface; this is indicative of a transient (impermanent) hyperemia

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9
Q

Define non-blanching hyperemia:

A
  • redness remains long after pressure is removed
  • indicating a degree of microcirculatory disruption often associated with other clinical signs, such as blistering, induration (localized hardening of the tissue)
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10
Q

Define ischemia:

A

reduce blood flow to tissue that is under pressure; may result in tissue death

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11
Q

What does a Braden scale assess?

A

A risk assessment tool to assess patients for risk of skin breakdown.

  • sensory perception
  • moisture
  • activity
  • mobility
  • nutrition
  • friction and shear
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12
Q

What is the difference between friction and shear?

A

Friction - a force that occurs in a direction opposite of movement creating heat ( heels, elbow, back of head @ greatest risk)

Shear - when underlying bone and soft tissues above them move in the opposite directions; involves gravity and friction(coccyx @ greatest risk)

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13
Q

List the pressure points at risk in supine position:

A
  • occiput (back of the head)
  • scalpel (upper back)
  • sacrum (lower back)
  • heels
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14
Q

List the pressure points at risk in lateral position:

A
  • ear
  • acromion process (below shoulder)
  • elbow
  • trochanter (below the hip)
  • medial & lateral condyle (below each knee)
  • medial ad lateral malleolus (each ankle bone)
  • heels
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15
Q

List the pressure points at risk in the prone position:

A
  • elbow
  • ear, cheek, nose
  • breasts (female)
  • genitalia (male)
  • iliac crest (very top of thigh)
  • patella (knee caps)
  • toes
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16
Q

List the pressure points at risk for a patient in a wheelchair:

A
  • hand, wrist, elbow
  • back of the upper and lower arm
  • shoulder blades and spine
  • coccyx
  • feet (heels and toes)
17
Q

Pressure-relieving devices indicate that amount of pressure is calculated by:

A

Dividing force by area.

Pressure = Force/area

18
Q

How can pressure injuries be prevented?

A
  • Braden scale
  • identify high-risk areas
  • maintain mobility and activity
  • use pressure-relieving devices
    reposition q2h
  • adequate food and fluids
19
Q

How can pressure injuries be managed?

A
  • team approach
  • reduce pressure (e.g elevate heels)
  • manage friction & shear (e.g by positioning HOB)
  • protect bony prominences
  • avoid unnecessary pads/sheets/clothing
  • decrease moisture
  • reposition q2h
20
Q

What are the risk factors for pressure injuries in older adults?

A
  • frail, nonambulatory, and/or neurologically impaired individuals
  • presence of illness and severity of it
  • involuntary weight loss
  • poor nutrition, dehydration, hypoproteinemia (low levels of protein in the blood), and vitamin deficiencies.
  • impaired sensory perception
  • impaired mobility
21
Q

What is tissue tolerance? What affects tissue tolerance?

A

the pressure that can be endured by tissue without impairing cellular respiration or causing ischemia(highly variable between body locations and persons).

affected by:
moisture
friction
shearing
amount of pressure
age

directly related to:
malnutrition
anemia
low arterial pressure

22
Q

People, who have vascular peripheral deficiencies are at high risk for pressure ulcers on what part of the body?

A

Heels

23
Q

Pressure ulcer complications include?

A

Wounds; infection; sepsis; needing grafting or amputation; death

24
Q

What term indicates redness of skin?

A

Hyperemia

25
Q

What nursing interventions help maintain skin integrity?

A
  • take action to eliminate friction and irritation to the skin (such as that caused by shearing)
  • reduce moisture so that tissues do not macerate (soften)
  • displace body weight from prominent areas in order to facilitate circulation
  • position changes, add pillows, establish a turning schedule
  • monitor nutritional intake (including serum albumin, hematocrit, and hemoglobin levels)
  • diet should be high in proteins, carbs, and vitamins to promote tissue growth (if pt lacks diet, can rx appetite stimulants)
  • consult wound care nurse
26
Q

Can a wound that is covered with necrotic tissue be staged?

A

NO; the necrotic tissue must be debrided or removed to expose the wound base to allow for assessment

N104 - Aging (6 decks)

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