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Modalities > Wound Care: Pressure Injuries > Flashcards

Wound Care: Pressure Injuries Flashcards

1
Q

pressure injury

A

areas of localized tissue destruction/damage caused by compression of soft tissue over a bony prominence and an external surface for prolonged period of time

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2
Q

3 examples/ names of pressure injuries

A

bedsore
decubitus ulcer
pressure sore

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3
Q

any surgery over _____ hours increases the risk of developing pressure injuries

A

3

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4
Q

why are pediatrics at higher risk of pressure injuries

A

they outgrow devices

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5
Q

T or F: patients with diabetes have a higher risk of pressure injuries

A

T

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6
Q

physiology of pressure injuries

A

compression > vascular insufficiency > tissue anoxia > cell death

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7
Q

how quickly can deformation of skin happen

A

10s of minutes

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8
Q

how quickly can ischemia of the skin happen

A

several hours

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9
Q

T or F: moisture and impaired circulation increases risk of pressur einjury

A

T

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10
Q

the use of _____ drugs increases the risk of pressure injuries

A

inotropic

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11
Q

4 forces related to pressure injuries

A

1 - pressure
2 - shear
3 - friction
4 - moisture

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12
Q

the ____ the bend, the more pressure you get in the sacral region

A

higher

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13
Q

common locations for pressure injuries

A
  • sacrum/coccyx
  • ischial tuberosity
  • heels
  • trochanters
  • posterior head
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14
Q

posterior head pressure injuries are more common in what population

A

pediatrics

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15
Q

what does the braden scale predict

A

pressure ulcer risk

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16
Q

class 1 pressure relief device

A

simple pressure pad devices (gel overlays, foam mattresses)

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17
Q

what are class 1 pressure relief devices used

A
  • a patient who cannot turn/move themselves to relieve pressure
  • pts who have a pressure injury on pelvis or trunk
18
Q

class 2 pressure relief device

A
  • relieves pressure over bony prominences for sustained periods of time
  • renaissance mattress, flotation mattress
19
Q

when are class 2 pressure relief devices used

A
  • pts with multiple pressure injuries that are not improving
  • pts with large stage 3/4 pressure injuries
20
Q

class 3 pressure relief device

A
  • advanced pressure relief device… air fluidized bed
  • clinitron bed
21
Q

when are class 3 pressure devices used

A
  • when a conservative treatment plan has failed after 30 days
22
Q

T or F: you do not have to turn pts if they are using a pressure relief device

A

false

23
Q

how should you encourage a pt to sleep unless it is contraindicated

A

with head of bed less than 30 degrees

24
Q

time when up in chair should be limited to ____ hours per episode

A

1-2

25
Q

how to help manage moisture to prevent pressur einjuries

A
  • only use an underpad if needed
  • only use adult diapers when out of bed
  • make sure to cleanse pt well if they have incontinence and apply a moisture barrier
26
Q

T or F: the heels should be floated at ALL times

A

T

27
Q

patients should be repositioned every ____ hours

A

2

28
Q

when positioning in sidelying, you should do a _____ degree lateral turn

A

30
*stay off bony prominences
*you should be able to visibly see that a pt is turned

29
Q

self-pressure relief options

A
  • boosting
  • leaning forward
  • weight-shift
  • recline
  • standing/walking
30
Q

why is boosting not ideal for most pts

A

you have to boost for at least 2 minutes to make a difference and that’s hard!

31
Q

why is it important to lift the heels when transferring a pt?

A

transfer sheets usually do not go all the way to the heels so that can cause friction when transferring

32
Q

deep tissue pressure injury

A

persistent non-blanchable deep red, maroon, or purple discoloration

33
Q

stage 1 pressure injury

A
  • skin is intact with a localized area of non-blanchable erythema
  • color changes do not include purple or maroon discoloration
34
Q

stage 2 pressure injury

A
  • partial thickness loss of skin with exposed dermis
  • wound bed is viable and may also present as a blister
  • no fat or deeper tissues visible, no slough or eschar
35
Q

if a pressure injury has any depth it is past a stage _____

A

2

36
Q

stage 3 pressure injury

A
  • full thickness loss of skin in which adipose is visible in the ulcer and granulation tissue and epibole are often present
  • may have slough or eschar
  • no muscle/tendon/lig are exposed
37
Q

if slough or eschar obscures the extent of tissue loss the wound it _____-

A

unstageable

38
Q

stage 4 pressure injury

A
  • full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, lig, cartilage, or bone in the ulcer
  • epibole, undermining, or tunneling often present
  • slough or eschar may be visible
39
Q

can mucosal membrane pressure injuries be staged

A

no, due to the anatomy

40
Q

T or F: you can back stage a pressure injury

A

F: for example, a stage 4 is always a stage 4. It can be a healing stage 4 or a healed stage 4

41
Q

you can assign _____ stage to a pressure injury

A

one

42
Q

how to treat pressure injuries

A

1 - reduce/eliminate pressure
2 - reduce friction/shear
3 - ther-ex
4 - ADLs
5 - manage incontinence
6 - nutrition
7 - bedrest is NOT the answer

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