Questions and Answers
List six stages of a pressure wound.
Stage 1: nonblanchable erythema of intact skin; Stage 2: Partial thickness skin loss with exposed dermis; Stage 3: Full thickness skin loss; Stage 4: Full thickness skin and tissue loss; Unstageable pressure injury: Observed full thickness skin and tissue loss; Deep tissue: Persistent non-blanchable deep red maroon, or purple discoloration.
What is a shear?
When layers of the skin rub against each other, or when the skin remains in place and underlying tissues move and stretch and tear underlying capillaries and blood vessels.
Where do pressure injuries usually occur?
Over bony prominences.
Why are older and disabled persons at a greater risk for pressure injuries?
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Describe a stage 2 pressure injury.
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Why do pressure injuries usually occur over the bony areas?
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What is an avoidable pressure injury?
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______ and ____________________ may signal infection.
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List four key pressure injury prevention measures for persons at risk.
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Explain why avoidable pressure injuries are preventable.
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Study Notes
Pressure Injury Stages
- Stage 1: Nonblanchable erythema on intact skin; redness that does not fade when pressed.
- Stage 2: Partial thickness skin loss through the epidermis, revealing the dermis.
- Stage 3: Full thickness skin loss, involving damage to the subcutaneous tissue.
- Stage 4: Extensive full thickness skin and tissue loss, exposing muscles, bones, or supporting structures.
- Unstageable: Full thickness loss where the base of the ulcer is covered by slough or eschar.
- Deep tissue injury: Persistent deep red, maroon, or purple discoloration indicating underlying tissue damage.
Shear Force
- Shear occurs when skin layers rub against each other or when skin remains fixed while underlying tissues move, leading to damaged capillaries and blood vessels.
Pressure Injury Locations
- Commonly develop over bony prominences such as heels, sacrum, elbows, and hips.
Risk Factors for Older Adults and Disabled
- Increased risk due to age-related skin changes, which reduce skin integrity and blood flow.
Stage 2 Pressure Injury Characteristics
- A stage 2 pressure injury presents as partial thickness skin loss, with the dermis exposed.
Pressure Points in Bony Areas
- Pressure injuries are likely to form over bony areas as these sites bear the body's weight during various positions.
Avoidable Pressure Injury Definition
- An avoidable pressure injury arises from inappropriate application of nursing processes, indicating lapses in care.
Signs of Infection
- Pain and delayed healing are indicators that may suggest an underlying infection.
Pressure Injury Prevention Measures
- Regularly move and reposition individuals to relieve pressure.
- Maintain skin hygiene and moisture to prevent breakdown.
- Use medical devices correctly to minimize pressure and friction.
- Implement proper nursing processes to monitor and manage skin integrity.
Preventable Nature of Avoidable Pressure Injuries
- With effective nursing procedures and vigilant care, avoidable pressure injuries can be completely prevented.
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Description
Test your knowledge on the stages of pressure injuries with these flashcards. This quiz covers critical definitions and classifications necessary for understanding wound care. Ideal for healthcare students and professionals alike.
