Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Pressure Injuries
| Question | Answer |
|---|---|
| Pressure injuries | ischemic lesions of the skin and underlying tissue caused by external pressure that impairs the flow of blood and lymph; tend to develop over bony prominence |
| necrosis | ischemia causes; dead tissue; eventual ulceration |
| may appear on the skin of any part of the body | that is subject to external pressure, friction, or sheering forces |
| sheering forces | result when one tissue layer slides over another |
| several factors contribute to the formation of the pressure injuries | immobility, inactivity, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, presence of chronic conditions |
| immobility | a reduction in the amount and control of movement |
| hypoproteinemia | abnormally low protein content in the blood |
| maceration | tissues softened by prolonged wetting or soaking; makes the skin more susceptible to erosions and injury |
| excoriation | the area of loss of the superficial layers of the skin, also known as a denuded area |
| six body positions | prone, supine, right and left side lateral, left sims |
| debridement | removal of necrotic material |
| eschar | a scab or dry crust consisting of dried plasma proteins and dead cells that forms over skin damaged by burns, infections, excoriations; prevents healing by granulation |
| stage 1 pressure injury | intact skin with localized redness that does not blanch when pressed |
| stage 2 pressure injury | shallow open wound or blister w/o slough |
| Stage 3 pressure injury | full thickness involving the subcutaneous tissue; epibole may be evident, adipose tissue may be vizualized |
| Stage 4 pressure injury | full thickness skin loss, extensive tissue damage and necrosis; fascia, muscle, ligament, cartilage, tendon, and/or bone may be vizualized |
| unstageable | full thickness tissue loss with depth completely obscured by slough or eschar in the wound bed |
| suspected deep tissue injury | intact skin with localized purple discoloration; possibly quick development of a thin blister or eschar |
| wound length | head to toe |
| wound width | side to side |
| depth | deepest part of wound |
| nurse notes | location, size in cm, presence of undermining, stage, color of wound bed, condition of margins, integrity of surrounding tissue, integrity of surrounding skin, s/s infection, pain |
| pressure on tissue between bony prominence and external surface | distorts capillaries, interferes w/ normal blood flow |
Created by:
melsniv
Popular Nursing sets