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)
Loading flashcards...

What are the risk factors for pressure injuries?

-advanced age
-critically ill
-hip fracture
-long or extensive surgical procedure
-low diastolic <60
-major trauma
-mental deterioration
-neurologic disorders
-peripheral vascular disease
-spinal cord injury


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


How fast can a patient get a pressure injury?

1-2 hours


-Non-blanchable erythema of intact skin
-may appear differently in darker skin

pressure injury stage 1


Partial Thickness skin loss with exposed dermis

pressure injury stage II


Wound bed visible– pink or red, moist
Fluid filled blister
Shearing injury

pressure injury stage II


Full-thickness skin loss

Pressure injury stage III


Adipose visible
Rolled wound edges
Slough/eschar may be visible (if obscures wound, unstageable)
Undermining and tunneling may occur

Pressure injury stage III


Full thickness skin AND tissue loss

Pressure injury stage IV


Exposed fascia, muscle, tendon, ligament, cartilage, or bone
Slough and/or eschar
Rolled edges, undermining and/or tunneling

Pressure injury stage IV


What causes a pressure injury to be unstageable?

because it is obscured by slough or eschar


-Persistent non-blanchable deep red, maroon or purple discoloration; may resemble a blood blister
-Prolonged pressure and sheer

Deep tissue injury


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


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