Flashcards in Inflammation, Wounds, and Pressure Ulcers part 6 Deck (14)
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1
What are the risk factors for pressure injuries?
-advanced age
-anemia
-contractures
-critically ill
-diabetes
-fever
-friction
-hip fracture
-immobility
-incontinence
-long or extensive surgical procedure
-low diastolic <60
-major trauma
-mental deterioration
-neurologic disorders
-pain
-peripheral vascular disease
-spinal cord injury
2
Damage to skin and underlying tissue occurs over a bony prominence or is related to the use of devices.
AKA: Decubitus ulcer, pressure sore, bedsore
pressure injuries
3
How fast can a patient get a pressure injury?
1-2 hours
4
-Non-blanchable erythema of intact skin
-may appear differently in darker skin
pressure injury stage 1
5
Partial Thickness skin loss with exposed dermis
pressure injury stage II
6
Wound bed visible– pink or red, moist
Fluid filled blister
Shearing injury
pressure injury stage II
7
Full-thickness skin loss
Pressure injury stage III
8
Adipose visible
Rolled wound edges
Slough/eschar may be visible (if obscures wound, unstageable)
Undermining and tunneling may occur
Pressure injury stage III
9
Full thickness skin AND tissue loss
Pressure injury stage IV
10
Exposed fascia, muscle, tendon, ligament, cartilage, or bone
Slough and/or eschar
Rolled edges, undermining and/or tunneling
Pressure injury stage IV
11
What causes a pressure injury to be unstageable?
because it is obscured by slough or eschar
12
-Persistent non-blanchable deep red, maroon or purple discoloration; may resemble a blood blister
-Prolonged pressure and sheer
Deep tissue injury
13
How do you assess a pt with dark skin?
-changes in color (darker, purple, brownish, bluish
-use natural or halogen light not fluorescent
-assess temp: may feel warm then cool
-feel consistency: boggy or edematous
-ask patient if itchy or painful
14
