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15 Cards in this Set
- Front
- Back
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Define Pressure Injury |
A localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device Pressure ulcer, decubitus, bed sores |
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Tissue Tolerance Extrinsic Factors |
1. Pressure - duration, intensity, and tolerance of skin and structures. Occludes blood flow causes tissue damage 2. Shearing- sliding of parallel surfaces against each other —pt slides down bed, forces reduce amount of pressure needed to occlude the blood vessels by up to 50% 3. Friction: lateral movement of pulling sheets/clothing from under a persons weight |
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Tissue Tolerance Intrinsic Factors |
1. Skin Structure and Function -advancing age -poor nutrition -steroids (skin breaks down) 2. Ability of the vascular system to provide circulation to the skin -smoking -vascular disease |
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Pressure Injury Stage 1 |
—Intact skin- non blanchable erythema, red/blue on dark skin —temperature changes —tissue consistency (boggy?) —sensation may be painful |
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Pressure Injury Stage 2 |
—Partial thickness skin loss —Res pink wound bed —No exposure of subcutaneous |
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Pressure Injury Stage 3 |
—Full thickness skin loss —Fat visible —Damage/necrosis of subcutaneous tissue may extend to fascia —Malleolus/ankle: less fat |
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Pressure Injury Stage 4 |
—Full thickness skin loss —Extensive destruction, tissue necrosis, muscle/bone damage —Undermining and Tunneling —Eschar and slough tissue —Risk of osteomyelitis (infection of bone) |
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Deep Tissue Pressure Injury |
Injury to subcutaneous tissue, Intact skin, deep colored bruise |
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Pressure Injury Colors |
Red: granulation tissue, cover the wound, keep moist and clean, protect from trauma Yellow: slough, clean the wound and remove the yellow layer Black: eschar, debris’s the wound (except on heels) |
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Common Pressure Injury Sites |
1. Back of head 2. Shoulder blade 3. Lower back 4. Heel 5. Sacrum 6. Hip 7. Elbow 8. Ear |
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Braden Scale |
For predicting pressure ulcer risk 1. Sensory Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and Shear Score 18 or less = Prevention Protocol (highest is 23) |
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Payne-Martin Classification |
Of skin tears Categories 1-3 1. Without tissue loss 2. Partial tissue loss 3. Complete tissue loss |
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Acute vs chronic urinary Incontinence |
Acute: Transient urinary incontinence Chronic: Established urinary incontinence |
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Types of Established Urinary Incontinence |
1. Stress - stressed/under pressure, often after child birth, during day 2. Urge - overactive bladder, sudden urge, little control, day and night, UTI 3. Mixed - more than one type, typically stress and urge 4. Overflow - incomplete emptying of bladder, BPH, day and night, increased PVR 5. Functional - physical limitation, cannot get to bathroom 6. Iatrogenic - irritants like medications, nicotine, caffeine, alcohol, etc |
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3 Things to help constipation |
1. Mobility 2. Fiber 3. Fluid intake |
