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AHII - Chapter 23
| Question | Answer |
|---|---|
| Pressure injury | Loss of tissue integrity -> results in reduced tissue perfusion & gas exchange -> eventually leads to cell death |
| Risk factors | Lack of mobility, exposure to excessive moisture, undernourishment, aging skin, cognitive decline or impairment, peripheral vascular disease or diabetes |
| Prevention | 1) Determine risk level 2) Reduce pressure 3) Improve pressure tolerance |
| Assessment | *Do not delegate to AP; document location, size, color, extent of tissue involvement, cell types in the wound base & margins, exudate, condition of the surrounding tissue, & presence of foreign bodies; dressing changes: compare last chart for changes |
| Stages/Types | 1: nonblanchable erythema of intact skin 2: partial-thickness loss with exposed dermis 3: full-thickness skin loss 4: full-thickness loss of skin & tissue Unstageable: obscured full loss Suspected deep-tissue: red, maroon, or purple Mucosal membrane |
| Braden Scale | Used to gauge pressure sore risk; lower the score, the higher the risk; 11 & under |
| Tunneling | “Hidden” wounds that extend from the primary wound into surrounding tissues |
| Techniques to better assess darker skin include: | Moisten the skin, long-wave infrared thermography, assess for blanching, cellulitis, eschar, granulation tissue, or undermining |
| Granulation | The formation of scar tissue for wound healing to occur |
| Undermining | Separation of the skin layers at the wound margins from the underlying granulation tissue |
| Serosanguineous Exudate | Blood-tinged amber fluid consisting of serum & red blood cells |
| Purulent Exudate | Pus (Yellow, greenish-blue, beige, or brown) |
| Lab assessment | If culture is needed, a tissue culture is done, not just a simple wound swab |
| Mechanical debridement | Mechanical entrapment & detachment of dead tissue |
| Topical chemical debridement | Topical enzyme preparations to loosen necrotic tissue |
| Natural chemical debridement | Promoting self-digestion of dead tissues by naturally occurring bacterial enzymes |
| Sharp debridement (Surgical) | Done before dressing is begun or continued & by health care provider; facilitates removal of excessive exudate & loose debris without damaging healthy epithelial cells or new granulation tissue |
| Common dressing techniques for wound debridement | Wet-to-damp saline-moistened gauze, continuous wet gauze, topical enzyme preparations, & moisture-retentive dressing |
Created by:
tatianalopez03
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