Pressure Injury Flashcards
(31 cards)
NPUAP
national pressure ulcer advisor pannel
what is a pressure injury
localized damage to skin and underlying soft tissue usually over a bony prominence or related to a medical or other device
where are common sites for pressure injury
hips, sacrum, heels, back of head
a pressure injury is usually caused in combination with
shear
what is the time and pressure for a pressure injury to develop
2hrs 30mmhg
what is shear
when you pull a patient up or they fall down and the inner and outer layer separate
risk factors for pressure injury
age (related skin changes)
immobility
obesity (no circulation)
thinness (decrease subq)
excessive moisture
poor nutrition/hydration
corticosteroids
previous pressure ulcer
DM
slough
necrotic tissue that is moist, stringy, and yellow or gray (devitalized tissue)
do you need to debride slough
yes
what stages is slough found in
3-4
eschar
devitalized dermis that has become leathery or thick and black
undermining
area of the ulcer beneath the skin surface that extends under the edge of the wound
tunneling
narrow extensions into the surrounding tissue
called sinus tract/fistula
stages of pressure injury
1-4, unstageable, deep tissue
stage 1
intact skin
non blanchable redness
stage 1 in dark pigment skin
may not have visible blanching, color differs form surrounding area
what do we need to protect stage 1 from
moisture, pressure, further injury
stage 2
partical thickness
red pink wound bed
open blister
skin is broken
stage 3
full thickness
subq visible
epibole (rolled edges)
slough and eschar
undermining/tunneling
stage 4
full thickness
exposed bone, ligament, tendon, muscle
slough or eschar
undermining and tunneling
epibole
if unsure between 1-2 and 3-4 what can you refer to them as
1-2: partial
3-4: full
unstageable is when
predominately wound bed is covered with slough or eschar
if the unstageable pressure wound is debrided what stage will it be at
3-4
deep tissue vs stage 1
deep tissue is purple or marron
