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Pressure Injuries
Pressure Injuries Fall 19 CCON
| Question | Answer |
|---|---|
| An injury that forms from a local interference with circulation | A pressure injury |
| When skin becomes pale it is called | blanching |
| If interference (pressure) removed | skin becomes darker as blood supply returns |
| reactive hyperemia | return of blood supply |
| Risk Factors for Pressure Injuries | Immobility Incontinence Diaphoresis Inadequate nutrition Lowered mental awareness Excessive diaphoresis Extreme age Edema |
| Skin Assessment for Pressure Injuries | Perform a skin assessment for pressure injury risk on admission Braden Scale Pay attention to the skin over bony prominences Check pressure areas when turning and repositioning your patient |
| Used in predicting pressure sore risk | Braden Scale |
| Three are ____ stages of pressure ulcers | 4 Stages of Pressure Injuries |
| area of reddened skin that does not blanch when touched Discoloration in people with dark skin; warmth, edema, or induration may be present | Stage I of Pressure Injuries |
| partial-thickness skin loss May look like an intact abrasion, ruptured blister, or shallow crater; surrounding skin may feel warmer; wound bed is pink or red and moist | Stage II of Pressure Injuries |
| full-thickness skin loss Looks like a deep crater; may extend into the fascia; subcutaneous tissue damaged or necrotic; yellow slough; visible fat | Stage III: of Pressure Injuries |
| full-thickness skin loss Extensive tissue necrosis or damage to muscle or supporting structures; may appear dry and black; necrotic tissue (eschar) | Stage IV: of Pressure Injuries |
| Prevention of Pressure Injuries | Excellent nursing care Your responsibility is to be aware of risk factors your patient may have and try to lessen them Prevention is |
| The main factor in preventing pressure injuries | Excellent nursing care |
| Less time-consuming and expensive than pressure injury treatment; assess skin carefully and frequently | Prevention |
| In Preventing Pressure Injuries avoid positioning directly on the _________________ | Trochanter |
| In preventing pressure injuries a patient's position should be changed how often | Every 2 hours |
| In preventing pressure injuries a patient's heels should be | Kept off the bed |
| Used to change positions and lift off the sheet in avoiding pressure injuries | Trapeze or lift sheet |
| Pressure reducing devices | Foam pads or mattresses |
| Should be used in patients in a wheel chair to prevent pressure injuries | pressure-reducing devices |
| How often should you Shift weight in patients to prevent pressure injuries | at least once an hour, preferably every 15 minutes |
| Restore circulation by rubbing around a reddened area but Do NOT massage these reddened areas | skin or over a bony prominence |
| When should the nurse Wash and dry incontinent patients | Promptly |
| Avoid mechanical injury from cast, braces, etc. Avoid skin injury caused by friction | Actions to avoid to reduce pressure injuries |
| Most effective in treatmentand Care for Pressure Injuries is via | a team approach Patient, family or caregivers, health care providers |
| Debridement, wound cleansing, and application of dressings | Initial care of a pressure injury |
| Used the injury is infected | Antibiotic therapy |
| Surgery needed to repair some pressure injuries T or F | True |
Created by:
TutorDavis17
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