Wound Care: Pressure Injuries Flashcards
pressure injury
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
3 examples/ names of pressure injuries
bedsore
decubitus ulcer
pressure sore
any surgery over _____ hours increases the risk of developing pressure injuries
3
why are pediatrics at higher risk of pressure injuries
they outgrow devices
T or F: patients with diabetes have a higher risk of pressure injuries
T
physiology of pressure injuries
compression > vascular insufficiency > tissue anoxia > cell death
how quickly can deformation of skin happen
10s of minutes
how quickly can ischemia of the skin happen
several hours
T or F: moisture and impaired circulation increases risk of pressur einjury
T
the use of _____ drugs increases the risk of pressure injuries
inotropic
4 forces related to pressure injuries
1 - pressure
2 - shear
3 - friction
4 - moisture
the ____ the bend, the more pressure you get in the sacral region
higher
common locations for pressure injuries
- sacrum/coccyx
- ischial tuberosity
- heels
- trochanters
- posterior head
posterior head pressure injuries are more common in what population
pediatrics
what does the braden scale predict
pressure ulcer risk
class 1 pressure relief device
simple pressure pad devices (gel overlays, foam mattresses)
what are class 1 pressure relief devices used
- a patient who cannot turn/move themselves to relieve pressure
- pts who have a pressure injury on pelvis or trunk
class 2 pressure relief device
- relieves pressure over bony prominences for sustained periods of time
- renaissance mattress, flotation mattress
when are class 2 pressure relief devices used
- pts with multiple pressure injuries that are not improving
- pts with large stage 3/4 pressure injuries
class 3 pressure relief device
- advanced pressure relief device… air fluidized bed
- clinitron bed
when are class 3 pressure devices used
- when a conservative treatment plan has failed after 30 days
T or F: you do not have to turn pts if they are using a pressure relief device
false
how should you encourage a pt to sleep unless it is contraindicated
with head of bed less than 30 degrees
time when up in chair should be limited to ____ hours per episode
1-2
how to help manage moisture to prevent pressur einjuries
- 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
T or F: the heels should be floated at ALL times
T
patients should be repositioned every ____ hours
2
when positioning in sidelying, you should do a _____ degree lateral turn
30
*stay off bony prominences
*you should be able to visibly see that a pt is turned
self-pressure relief options
- boosting
- leaning forward
- weight-shift
- recline
- standing/walking
why is boosting not ideal for most pts
you have to boost for at least 2 minutes to make a difference and that’s hard!
why is it important to lift the heels when transferring a pt?
transfer sheets usually do not go all the way to the heels so that can cause friction when transferring
deep tissue pressure injury
persistent non-blanchable deep red, maroon, or purple discoloration
stage 1 pressure injury
- skin is intact with a localized area of non-blanchable erythema
- color changes do not include purple or maroon discoloration
stage 2 pressure injury
- 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
if a pressure injury has any depth it is past a stage _____
2
stage 3 pressure injury
- 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
if slough or eschar obscures the extent of tissue loss the wound it _____-
unstageable
stage 4 pressure injury
- 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
can mucosal membrane pressure injuries be staged
no, due to the anatomy
T or F: you can back stage a pressure injury
F: for example, a stage 4 is always a stage 4. It can be a healing stage 4 or a healed stage 4
you can assign _____ stage to a pressure injury
one
how to treat pressure injuries
1 - reduce/eliminate pressure
2 - reduce friction/shear
3 - ther-ex
4 - ADLs
5 - manage incontinence
6 - nutrition
7 - bedrest is NOT the answer
