Podcast
Questions and Answers
A patient has a pressure injury with full-thickness skin loss, visible adipose tissue, and rolled wound edges. Which stage is this injury?
A patient has a pressure injury with full-thickness skin loss, visible adipose tissue, and rolled wound edges. Which stage is this injury?
- Unstageable
- Stage 2
- Stage 3 (correct)
- Stage 4
Which of the following is the primary characteristic of a Stage 1 pressure injury?
Which of the following is the primary characteristic of a Stage 1 pressure injury?
- Full-thickness skin and tissue loss obscured by slough
- Non-blanchable erythema of intact skin (correct)
- Partial-thickness skin loss with exposed dermis
- Full-thickness skin loss with exposed muscle
What is the primary goal of debridement in the treatment of pressure injuries?
What is the primary goal of debridement in the treatment of pressure injuries?
- To prevent the formation of granulation tissue
- To decrease the amount of exudate
- To promote the formation of an eschar
- To remove necrotic tissue and promote healing (correct)
When documenting undermining in a wound, which method is recommended for accuracy and consistency?
When documenting undermining in a wound, which method is recommended for accuracy and consistency?
Which intervention is most important when preventing pressure injuries related to medical devices?
Which intervention is most important when preventing pressure injuries related to medical devices?
A patient at risk for pressure injuries is being repositioned in bed. What is the MOST appropriate technique to minimize shear forces?
A patient at risk for pressure injuries is being repositioned in bed. What is the MOST appropriate technique to minimize shear forces?
Which type of debridement uses the body's own enzymes to break down necrotic tissue?
Which type of debridement uses the body's own enzymes to break down necrotic tissue?
You are educating a client and their family about strategies to prevent pressure injuries. Which of the following instructions is MOST appropriate regarding positioning?
You are educating a client and their family about strategies to prevent pressure injuries. Which of the following instructions is MOST appropriate regarding positioning?
Which of the following is the MOST appropriate cleansing agent for a pressure injury?
Which of the following is the MOST appropriate cleansing agent for a pressure injury?
A patient has a pressure injury. When assessing the wound, which of the following should be documented?
A patient has a pressure injury. When assessing the wound, which of the following should be documented?
Flashcards
Pressure Injury
Pressure Injury
Localized damage to the skin and/or underlying tissue, usually over a bony prominence, due to pressure, shear, or friction.
Pressure Injury Risk Factors
Pressure Injury Risk Factors
Impaired mobility, incontinence, inadequate nutrition, decreased sensory perception, and compromised circulation.
Braden Scale
Braden Scale
A tool used to evaluate a patient's risk for developing pressure injuries.
Stage 1 Pressure Injury
Stage 1 Pressure Injury
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Stage 2 Pressure Injury
Stage 2 Pressure Injury
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Stage 3 Pressure Injury
Stage 3 Pressure Injury
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Stage 4 Pressure Injury
Stage 4 Pressure Injury
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Unstageable Pressure Injury
Unstageable Pressure Injury
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Deep Tissue Pressure Injury (DTPI)
Deep Tissue Pressure Injury (DTPI)
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Debridement
Debridement
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Study Notes
- Pressure injuries, formerly known as pressure ulcers, are localized damage to the skin and/or underlying tissue, usually over a bony prominence, resulting from pressure, or pressure combined with shear and/or friction.
- Risk factors for pressure injuries include impaired mobility, incontinence, inadequate nutrition, decreased sensory perception or cognitive awareness, and compromised circulation.
- The Braden Scale assesses a patient's risk for developing pressure injuries based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
- Pressure injuries are staged to classify the depth and extent of tissue damage:
- Stage 1: Non-blanchable erythema of intact skin.
- Stage 2: Partial-thickness skin loss with exposed dermis.
- Stage 3: Full-thickness skin loss, with visible adipose (fat) and often granulation tissue and epibole (rolled edges).
- Stage 4: Full-thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone.
- Unstageable: Full-thickness skin and tissue loss where the extent of damage is obscured by slough or eschar.
- Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration.
- Prevention involves regular skin assessments, pressure redistribution, moisture management, nutritional support, and education.
- Pressure redistribution uses specialized support surfaces, frequent repositioning, and offloading pressure from bony prominences.
- Proper skin care includes keeping skin clean and dry, using moisturizers, and avoiding harsh soaps or irritants.
- Nutritional support, including protein, calories, vitamins, and minerals, is essential for wound healing.
- Education for patients and caregivers should cover risk factors, prevention strategies, and proper skin care.
- Treatment depends on the stage and severity and includes debridement, wound cleansing, dressing selection, pain management, and infection control.
- Debridement removes necrotic tissue or debris through sharp, mechanical, enzymatic, or autolytic methods.
- Wound cleansing should use gentle irrigation with normal saline or a prescribed cleanser.
- Dressing selection depends on wound characteristics like drainage, depth, and infection, and may include moisture-retentive, antimicrobial dressings, or negative pressure wound therapy.
- Pain management can include pharmacological or non-pharmacological interventions.
- Infection control includes hand hygiene and sterile technique during dressing changes.
- Monitoring healing involves assessing wound size, depth, exudate, granulation tissue, or epithelialization, and adjusting the treatment plan.
- Interdisciplinary collaboration among nurses, physicians, dietitians, and wound care specialists is essential.
- Medical devices can cause pressure injuries.
- Padding can prevent pressure injuries from medical devices.
- Wounds are measured by length, width, and depth.
- Undermining and tunneling should be documented using the clock method.
- Preventative interventions include optimizing nutrition and hydration, minimizing pressure, and managing moisture.
- Documentation should include the stage, location, size, color, tissue type, condition of wound edges, presence of undermining or tunneling, and signs of infection.
- Nutrition and hydration needs should be based on individual health status.
- Educate clients and families on positioning and repositioning techniques.
- Specialty beds can help redistribute pressure.
- Use proper lifting techniques to avoid shearing.
- Clean skin at time of soiling and at routine intervals, using skin moisturizers for dry skin.
- Avoid positioning directly on the trochanter; use a 30-degree lateral inclined position for side-lying.
- Float heels off the bed and use devices to reduce shear.
- Nutritional support includes protein, calories, vitamins, and minerals.
- Educate the patient and family.
- Debridement is the removal of necrotic tissue.
- Debridement types:
- Autolytic: Uses the body's enzymes and moisture to re-hydrate, soften, and liquefy eschar and necrotic tissue.
- Enzymatic: Topical enzymes break down necrotic tissue.
- Mechanical: Physical removal of debris by irrigation, hydrotherapy, or wet-to-dry dressing application.
- Sharp/Surgical: Sharp instruments cut away devitalized tissue or eschar.
- Wound cleansing should be performed with normal saline.
- Wound dressings should maintain a moist wound environment.
- Control pain and minimize infection.
- Negative pressure wound therapy uses a vacuum dressing to promote healing.
- Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurized environment.
- Pressure injuries can lead to serious complications such as infection, pain, increased length of stay, and decreased quality of life.
- Prevention is key.
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