types of injuries Flashcards
where are pressure ulcers most commonly found and what causes them?
sacrum and heels
results from prolonged pressure or pressure in combination with shearing force
will generally heal by secondary intention
what pathophysiological processes occur when a pressure ulcer is forming?
stop capillary flow to the tissues
deprives tissues of oxygen and nutrients
cell death aka tissue necrosis
the influencing factors of pressure ulcers are what?
pressure intensity
pressure duration
tissue tolerance factors
shearing forces
moisture
what things contribute to the ability of the tissues to tolerate pressure?
nutrition
perfusion
co-morbidities
condition of soft tissue
list the factors that put people at risk for getting pressure ulcers
advanced age
anemia
diabetes
elevated body temperature
friction
immobility
incontinence
impaired circulation
low diastolic BP
mental deterioration
neurological disorders
obesity
pain
prolonged surgery
vascular disease
ability to stage a pressure ulcer depends on what?
extent of tissues involved
visible or palpable tissue in the ulcer bed
national pressure ulcer advisory panel guidelines
presence of slough or eschar may prevent staging until it is removed
what are characteristics of a deep tissue injury?
purple or maroon localized area of discolored intact skin or blood-filled blister
can be preceded by tissue that is painful, firm, mushy, and boggy
this indicates damage of underlying soft tissue from pressure or sheer
what are the four things that you assess for in darker skin patients?
darker areas of skin surrounding the area being assessed
skin temperature of the affected area and the area surrounding
skin/tissue consistency
patient sensation; may report itchy or painful
what categorizes a stage 1 pressure ulcer?
intact skin that is nonblanchable in a localized area
may be painful, soft, firm, warmer, or cooler compared to adjacent tissue
what categorizes a stage 2 pressure ulcer?
partial-thickness loss of dermis
shallow open ulcer with red/pink wound bed
intact or rupture serum-filled blister
shiny or dry shallow ulcer without sloughing or bruising
fat tissue, granulation tissue, slough, and eschar arent present
what categorizes a stage 3 pressure ulcer?
full-thickness skin loss
subcu tissue may be visible but bone, tendon, or muscle are not
presents as deep crater with possible undermining or adjacent tissue
what categorizes a stage 4 pressure ulcer?
full-thickness loss extends to muscle, bone, or supporting structures
bone,tendon, or muscle may be visible or palpable
undermining and tunneling may occur
slough or eschar may be present on some parts of the wound bed
unstageable ulcers can be categorized by what factors?
full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
slough or eschar must be removed to expose the base of the wound in order to stage
stable, dry eschar on heels should not be removed
An unstageable ulcer can have slough present, what does slough look like?
yellow
tan
green
gray
brown
an unstageable ulcer can have eschar present, what does eschar look like?
tan
brown
black
what can some complications be of pressure ulcers?
infection
repeat ulcers
repeat pressure injury/tissue breakdown
cellulitis
infections can cause complications in pressure ulcers but what type of infections can occur?
leukocytosis
fever
increased ulcer size, odor, or drainage
necrotic tissue
indurated, warm, and painful
what can cause cellulitis and what can cellulitis cause?
untreated ulcers
spread of inflammation/infection to subcutaneous tissue, connective tissue, and bone
thus leading to sepsis and death
prevention measures for pressure ulcers involve what?
redistribution of pressure
keep skin dry (apply barrier ointment if incontinence)
reposition the drawsheet/transfer board, position patient at 30 degrees lateral position, HOB at 30 degrees or less
turning schedule
nutrition and fluid intake
what are some surgical treatments if the pressure ulcer gets bad enough?
skin graft
skin flap
musculocutaneous flaps
how does the skin appear if an arterial ulcer is present?
thin
shiny
dry
loss of hair on ankles and feet
even wound margins
pale deep wound bed
where can aterial ulcers be found?
between toes or on tips of toes
on phalangeal head
lateral malleous
or any area with rubbing footwear
what causes arterial uclers?
ischemia and nutrition deprivation as a result of decreased circulation
what patients are at a higher risk of getting arterial ulcers?
atherosclerosis
PVD
diabetes
smoking
hypertension
advanced age
obese
cardiovascular disease
