Week 10 - Pressure Injury

Question 1

What is a pressure injury? (2)

Answer 1

• Any lesion caused by unrelieved pressure
• results in damage to underlying tissues

Question 2

What is a pressure ulcer?

Answer 2

• occurs over a bony prominence and are staged to classify the degree of tissue damage observed

Question 3

How can we reduce the risk of pressure injury? (3)

Answer 3

• Identify risk
• Monitor older adults who are at risk
• Preventions/assessments (skin, do activities, etc.)

Question 4

What is in the top three safety concerns for institutionalized patients? (2)

Answer 4

pressure ulcers
- these are preventable, but remain prevalent in LTC settingd

Question 5

What are the risks of having a pressure injury? (3)

Answer 5

• associated with increased length of stay in hospitals
• Increased mortality
• increased rate of bacteremia and multi-drug resistant organisms

Question 6

How can pressure injuries impact someones life? (2)

Answer 6

• decrease social wellbeing and quality of life
• high tx costs

Question 7

Who is more at risk for developing pressure injuries? (10)

Answer 7

1. Frailty
2. Immobility or neurologically impaired
3. Acute Illness
4. Weight loss (decreased subcut)
5. Poor nutrition + dehydration
6. Hypoproteinemia
7. Impaired sensory feedback system like diabetes
8. Moist skin
9. Sedated or unconscious
10. Ventilation requiring head of the bed elevation

Question 8

What is tissue tolerance?

Answer 8

• factors that impact the degree to which tissue is able to tolerate persistent pressure

Question 9

Which factors impact tissue tolerance? (4)

Answer 9

1. Blood vessels constricted by persistent pressure on the skin and underlying structures
2. Cellular respiration is impaired
3. cells die from ischemia and anoxia
4. Inversely affected by moisture, friction, shearing, pressure, age, nutrition, anemia, low arterial pressure

Question 10

Which assessment tool assesses for risk factors of pressure ulcers?

Answer 10

Braden scale

Question 11

How can we identify risks of pressure injuries? In other words, what can we do as nurses to prevent them? (2)

Answer 11

• close monitoring of skin
• Initiate appropriate interventions (interprofessional collaborations) to prevent further skin breakdown and promote healing

Question 12

In what ways can we observe and assess skin conditions? (5)

Answer 12

1. daily H2T assessments of persons at risks on bony prominences
   - Hyperemia (redness, hard to see in dark-skinned)
   - Changes in temperature
   - check existing injuries
   - Assess pain and discomfort

Question 13

in lecture, how can we observe skin conditions based on nutritional intake?

Answer 13

• Blood levels of albumin, hct, and hgb
• but particularly albumin