Week 7: Pressure Injury Risk Care Flashcards
1
Q
What is a pressure ulcer?
A
- Any lession caused by unrelieved pressure including shearing and friction forces
2
Q
Risk Factors to formation of pressure injuries
A
- Friction and Shearing force
- Immobility
- Inadequate Nutrition
- Faecal and Urinary Incontinence
3
Q
Pressure Injury Stage I
A
- Non-blanachable erythema
- Intact skin with non-blanch able redness of a localised area usually over a bony promience
- Area may be painful, firm, softer, warmer or cooler compared to adjacent tissue
4
Q
Pressure Injury Stage II
A
- Partial Thickness Skin Loss
- Partial thickness loss of dermis presenting as a shallow open wound with a red-pink wound bed, without slough
- May present as an intact or open/ruptured serum-filled blister
5
Q
Pressure Injury Stage III
A
- Full thickness skin loss
- Subcutaneous fat may be visible but bone, tendon, muscle are not exposed. Slough may be present but does not obscure the depth of the tissue fulls
- The depth of a stage III PI varies by anatomical location
6
Q
Pressure Injury Stage IV
A
- Full Thickness Tissue loss
- Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed
7
Q
Unstageable Pressure Injury
A
- Depth Unknown
- Full thickness tissue loss in which the base of the pressure injury is covered by slough (yellow
8
Q
Suspected deep tissue
A
- Depth Unknown
- Purple or maroon localised area or discoloured, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
9
Q
Pressure injury risk factors
A
- Poor Nutrition
- Immobile
