Week 6: Pressure Injury Flashcards
What are the risk factors for pressure injuries?
Advanced age, critical illness, immobility, fever, poor nutrition, decreased sensory perception, cognitive impairment, anemia, diabetes, poor temperature control/hyperhidrosis, poor hygiene, peripheral vascular disease
What is a pressure injury?
localized injury to skin and/or underlying tissue as a result of excessive or prolonged pressure, shear and/or friction
What are the causes of pressure injuries?
Prolonged pressure, shear, and/or friction
What defines a stage I pressure ulcer?
Erythema of the skin, blanchable or non-blanchable
What is generally involved in a pressure ulcer risk assessment?
Activity and mobility level
General condition of the skin
Nutrition status
Presence of coexisting problems (diabetes, cardiovascular conditions)
Fecal and urinary incontinence
General skin moisture
What areas are at greater risk for pressure injuries?
Bony prominences (hips, shoulders, buttocks, heels), skin folds and perineal areas
What interprofessional members can be consulted for pressure injury assessment/management?
Dietician (nutrition assessment) and wound care specialist (for interventions to manage injury)
How do alternating pressure mattresses aid in pressure injury management?
They “off-load” pressure points by redistributing pressure over a larger surface, reducing the pressure on especially vulnerable parts of the body.
What diet would be expected to promote wound healing?
High in protein, carbohydrate, and vitamins with moderate fat intake helps promote healing.
The caloric intake needed may be 30 to 35 calories/kg/day with 1.25 to 1.50 g of protein/kg/day.
Also require adequate hydration.
What can occur when a wound is packed too full?
As wounds heal, they contract. If a wound is packed too tightly, it creates a pressure insult to the wound bed and causes a secondary pressure injury or further tunneling.
What would you expect a stage 3 wound to look like?
A stage 3 injury has full-thickness tissue loss. Subcutaneous fat tissue might be visible, but bone, tendon, and muscle are not exposed. Slough can occur but will not obscure the depth of tissue loss. This is usually a deep crater with undermining or tunneling present.
What are the risk factors for wound tunnelling?
Infections, non healing wounds, improperly dressed wounds, dehydrating wounds, too much or too little packing
When collecting a wound culture with a swab, the WOCN would culture the
a. wound drainage
b. healthy-appearing tissue
c. most necrotic-appearing tissue
d. very outer edges of the wound
b
Culture the healthiest-appearing tissue in the center of the wound.
What factors influence the choice of wound dressing?
Type of tissue in the base of the wound, amount and type of drainage, presence of infection, size and location of the wound, undermining, tunnelling, edema, cost effectiveness and comfort of the pt
What defines a stage 2 pressure ulcer?
erythema with loss of partial thickness of the skin including epidermis and part of the superficial dermis
