Podcast
Questions and Answers
What physiological process is most directly compromised when tissue is compressed for an extended period, leading to a pressure injury?
What physiological process is most directly compromised when tissue is compressed for an extended period, leading to a pressure injury?
- Collagen synthesis
- Nerve impulse transmission
- Lymphatic drainage
- Blood flow to the skin (correct)
Which of the following factors contributes to the development of pressure injuries by increasing the susceptibility of the skin to damage?
Which of the following factors contributes to the development of pressure injuries by increasing the susceptibility of the skin to damage?
- Increased sensory perception
- Malnutrition (correct)
- Hydration
- Skin elasticity
Why is direct massage avoided on reddened skin areas?
Why is direct massage avoided on reddened skin areas?
- It can stimulate nerve regeneration, causing discomfort
- It can further damage capillary beds and cause tissue necrosis (correct)
- It interferes with topical medication absorption
- It may increase the risk of infection
What is the primary rationale for repositioning an immobile client every two hours?
What is the primary rationale for repositioning an immobile client every two hours?
What type of exudate would be expected in the initial 48 hours of a pressure injury?
What type of exudate would be expected in the initial 48 hours of a pressure injury?
The presence of purulent exudate from a pressure injury most likely indicates:
The presence of purulent exudate from a pressure injury most likely indicates:
Which nursing intervention is essential for preventing pressure injuries, especially in clients with incontinence?
Which nursing intervention is essential for preventing pressure injuries, especially in clients with incontinence?
Why is it important to monitor and record the location, size (length, width, depth), and characteristics of exudates from a pressure injury?
Why is it important to monitor and record the location, size (length, width, depth), and characteristics of exudates from a pressure injury?
Why is documentation with photographs sometimes required for pressure injuries?
Why is documentation with photographs sometimes required for pressure injuries?
Which intervention is often included in the treatment plan for a pressure injury?
Which intervention is often included in the treatment plan for a pressure injury?
What is the underlying cause of tissue damage in a pressure injury?
What is the underlying cause of tissue damage in a pressure injury?
Which of the following is a risk factor for developing pressure injuries?
Which of the following is a risk factor for developing pressure injuries?
What is the purpose of using creams and lotions for the incontinent client:
What is the purpose of using creams and lotions for the incontinent client:
What nursing action can reduce the risk of pressure injuries when caring for bedridden patients?
What nursing action can reduce the risk of pressure injuries when caring for bedridden patients?
When monitoring the skin of a patient, what should a nurse look for as an early sign of a possible pressure injury?
When monitoring the skin of a patient, what should a nurse look for as an early sign of a possible pressure injury?
Which of the following is a key component of care to prevent pressure injuries?
Which of the following is a key component of care to prevent pressure injuries?
How does skin shearing and friction contribute to the development of pressure injuries?
How does skin shearing and friction contribute to the development of pressure injuries?
Which nursing intervention is crucial for preventing pressure injuries in clients with limited mobility?
Which nursing intervention is crucial for preventing pressure injuries in clients with limited mobility?
After the initial 48 hours of a pressure injury, which type of exudate is cause for concern and indicates a potential complication?
After the initial 48 hours of a pressure injury, which type of exudate is cause for concern and indicates a potential complication?
When documenting a pressure injury, what information is essential to include?
When documenting a pressure injury, what information is essential to include?
The primary reason for avoiding direct massage to a reddened skin area is to prevent:
The primary reason for avoiding direct massage to a reddened skin area is to prevent:
What is the most important reason for nurses to identify clients at risk for developing pressure injuries?
What is the most important reason for nurses to identify clients at risk for developing pressure injuries?
What does agency protocol for skin assessment and wound management ensure in the context of pressure injuries?
What does agency protocol for skin assessment and wound management ensure in the context of pressure injuries?
What's the primary goal of debridement procedures in the treatment of pressure injuries?
What's the primary goal of debridement procedures in the treatment of pressure injuries?
A key factor in the development of pressure injuries is tissue compression between a bony prominence and:
A key factor in the development of pressure injuries is tissue compression between a bony prominence and:
Which of the following is an appropriate measure to prevent pressure injuries?
Which of the following is an appropriate measure to prevent pressure injuries?
For clients who spend long periods of time in bed, what measure helps prevent pressure injuries?
For clients who spend long periods of time in bed, what measure helps prevent pressure injuries?
Which of the following is a potential treatment for necrosis due to pressure injury?
Which of the following is a potential treatment for necrosis due to pressure injury?
What is the primary consideration when using agency protocols for skin assessment and management of wounds?
What is the primary consideration when using agency protocols for skin assessment and management of wounds?
What should nurses avoid doing when caring for a patient with reddened skin, a precursor to pressure injury?
What should nurses avoid doing when caring for a patient with reddened skin, a precursor to pressure injury?
A nurse notes serosanguineous drainage from a patient's pressure injury. What is the appropriate nursing action?
A nurse notes serosanguineous drainage from a patient's pressure injury. What is the appropriate nursing action?
A patient at risk of pressure injuries may require which type of documentation?
A patient at risk of pressure injuries may require which type of documentation?
What is the rationale behind providing active and passive range-of-motion exercises?
What is the rationale behind providing active and passive range-of-motion exercises?
Which intervention is most important for a client at risk for pressure injuries in relation to moisture?
Which intervention is most important for a client at risk for pressure injuries in relation to moisture?
Why is immobility considered a significant risk factor for developing pressure injuries?
Why is immobility considered a significant risk factor for developing pressure injuries?
Which outcome indicates effective teaching about pressure injury prevention?
Which outcome indicates effective teaching about pressure injury prevention?
Flashcards
Pressure Injury
Pressure Injury
Impairment of skin integrity due to compression between a bony prominence and an external surface, leading to tissue damage.
Tissue Compression Consequence
Tissue Compression Consequence
The restriction of blood flow to the skin due to tissue compression, potentially leading to ischemia, inflammation, and necrosis.
Massage on Reddened Skin
Massage on Reddened Skin
Direct massage can damage capillary beds and cause tissue necrosis.
Pressure Injury Prevention
Pressure Injury Prevention
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Skin Integrity Monitoring
Skin Integrity Monitoring
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Skin Condition
Skin Condition
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Skin Lubrication and Protection
Skin Lubrication and Protection
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Repositioning Frequency
Repositioning Frequency
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Wound Assessment
Wound Assessment
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Serosanguineous Exudate
Serosanguineous Exudate
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Purulent Exudates
Purulent Exudates
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Pressure Injury Treatment
Pressure Injury Treatment
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Risk Factors
Risk Factors
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Study Notes
- A pressure injury impairs skin integrity.
- Pressure injuries can occur anywhere on the body and results when the skin and underlying tissue are compressed between a bony prominence and an external surface for an extended period of time.
- Blood flow restriction to the skin can result in tissue ischemia, inflammation, and necrosis.
- Pressure injuries are difficult to heal once developed.
Risk factors
- Skin pressure is a risk factor.
- Skin shearing and friction can cause injuries.
- Immobility is considered a risk factor.
- Malnutrition is a risk factor for pressure injuries.
- Incontinence increases risk.
- Decreased sensory perception increases the risk of pressure injuries.
Nursing Interventions
- Avoid direct massage to reddened skin as it can damage capillary beds and cause tissue necrosis.
- Identify clients at risk for developing a pressure injury.
- Institute measures to prevent pressure injuries with:
- Appropriate positioning
- Pressure relief devices
- Adequate nutrition
- A plan for skin cleansing and care
- Check the skin frequently and monitor for alterations in skin integrity.
- Keep the client's skin dry and the sheets wrinkle-free.
- With incontinence, check the client frequently.
- Change pads or any soiled items immediately.
- Use creams and lotions to lubricate the skin.
- Use a barrier protection ointment for incontinent clients.
- Turn and reposition immobile clients every 2 hours, or more frequently if necessary.
- Provide active and passive range-of-motion exercises at least every 8 hours.
- If a pressure injury is present:
- Record the location and size of the wound (length, width, depth).
- Monitor and record the type and amount of exudates; a culture may be prescribed.
- Check for undermining and tunneling.
- Serosanguineous exudate (blood-tinged amber fluid) is expected for the first 48 hours.
- Purulent exudates indicate colonization of the wound with bacteria.
- Use agency protocols for skin assessment and wound management.
- Picture documentation may be required on file of a pressure injury:
- Client identifier
- Measuring device
- A label indicating wound laterality and location
- Picture documentation may be required on file of a pressure injury:
- Treatment may include wound dressings and debridement procedures.
- Skin grafting may be necessary.
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