PRESSURE INJURIES Flashcards
(17 cards)
What is a Pressure Injury?
Localized damage to skin and tissue from pressure, shear, or friction, Often develops over bony prominences
What does a Stage 1 pressure injury look like?
Red, non-blanchable, intact skin.
What characterizes a Stage 2 pressure injury?
Partial-thickness loss with exposed dermis, red/pink wound bed, can be an intact or ruptured serum-filled blister.
What is visible in a Stage 3 pressure injury?
Full-thickness skin loss; adipose tissue is visible, but no exposed muscle, tendon, ligament, cartilage, or bone.
Q: What differentiates a Stage 4 pressure injury from Stage 3?
Full-thickness tissue loss with exposed bone, tendon, or muscle.
When is a pressure injury considered “unstageable”?
When full-thickness loss is obscured by slough or eschar and depth cannot be determined until cleaned/debrided.
How the Deep Tissue Injury (DTI) look like ?
Purple or maroon discoloration or a blood-filled blister.
What is the main cause of medical device-related pressure injuries?
Tubes, braces, or other medical equipment at device contact points.
Why are pediatric patients at high risk for pressure injuries?
Due to pressure at occiput and ears.
What does the Braden Scale assess?
Sensory perception, moisture, activity, mobility, nutrition, friction/shear; higher scores indicate lower risk.
What is different about the Braden Q Scale?
Modified for children; includes tissue perfusion/oxygenation and lacks a moisture element.
What is undermining in wound assessment?
Tissue destruction under intact skin edges, measured using a sterile probe.
How is a Stage 1 or DTI managed?
Apply silicone foam dressing, replace dressing every 24 hours, avoid pressure, and inspect skin underneath every shift.
What is the primary dressing for a Stage 2 pressure injury?
Hydrofiber as the primary dressing over the wound bed, along with silicone foam dressing.
Q: How should Stage 3 & 4 pressure injuries be managed initially?
Hydrofiber as the primary dressing over the wound bed, along with silicone foam dressing.until the physician provides new orders
What must be assessed in pressure injury management?
Size, depth, exudate, tissue type, and photo documentation with consent.
Who should be involved in collaboration for complex pressure injury cases?
Wound care specialists, nutritionists, and physical therapists as needed.
