Inflammation, Wounds, and Pressure Ulcers part 6 Flashcards Preview

Test 3 > Inflammation, Wounds, and Pressure Ulcers part 6 > Flashcards

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

What are some ways to prevent pressure injuries?

-assess skin
-incontinent care
-skin moisturizer
-turn Q 2 hours bed
-trun Q 1 hour chair
-HOB 30 degrees or less
-pressure relieving devices