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Pressure Injuries

Pressure Injuries Fall 19 CCON

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