pressure injuries

Question 1

what is the primary intervention for pressure injuries

Answer 1

prevention
(Q2turn, skin dry and clean, barrier cream, nutrition, foam boots, braden scale)

Question 2

what are some causes of pressure injuries

Answer 2

-pressure intensity (causes constriction of blood flow -> decreased O2 and nutrition to tissue -> tissue ischemia)
-pressure duration (longer time = more risk)

Question 3

what are some risks for pressure injuries

Answer 3

impaired tissue tolerance
-nutrition
-moisture
-age
-friction
-shear

Question 4

risks

nutrition

Answer 4

-calories and protein are necessary to rebuild cells and tissues
-vitamin C and fluids are necessary

Question 5

risks

moisture

Answer 5

prolonged moisture on skin reduces the skins resistance to trauma

Question 6

risks

age

Answer 6

aging skin is more susceptible to injury

Question 7

risks

friction

Answer 7

-occurs when two surfaces rub against each other
-damages superficial blood vessels under the skin

Question 8

risks

shear

Answer 8

-one layer of tissue slides over another layer
-separates one layer of skin from underlying tissue

Question 9

what are some comorbid conditions r/t pressure injuries

Answer 9

-altered LOC
-sensory impairment (cant feel it)
-impaired mobility (can feel it but cant do shit about it)

Question 10

look at this shit

Answer 10

Question 11

describe stage I pressure injury

Answer 11

tx includes relieving pressure, cleaning area, and placement of a dressing

Question 12

describe stage II pressure injury

Answer 12

-tx is similar to stage I - relieve pressure and place dressing
-shallow

Question 13

describe stage III pressure injury

Answer 13

-can have tunneling or undermining
-requires frequent dressing changes and nutritional intervention

Question 14

describe stage IV pressure injury

Answer 14

-requires frequent dressing changes, pressure relieving surfaces and wound care
-can take months to years to heal

Question 15

what is slough

Answer 15

-yellow, tan, gray, green, or brown
-non viable tissue

Question 16

describe eschar

Answer 16

-dark brown or black
-crust like, nonviable tissue

Question 17

describe and unstageable pressure injury

Answer 17

-full thickness tissue damage
-base of the wound is covered by slough or eschar

Question 18

describe suspected deep tissue injury (SDTI)

Answer 18

purple or maroon localized area of intact skin

Question 19

describe autolytic debridement

Answer 19

-use of hydrocolloid or foam dressings
-body’s own enzymes and defensive mechanisms to loosen and liquify necrotic tissue

Question 20

describe bio-surgical debridement

Answer 20

-use of surgical grade/sterile fly larvae
-larvae secrete enzyme that liquifies necrotic tissue, then larvae consumes liquid and infectious material in the wound

Question 21

describe enzymatic debridement

Answer 21

-application of commerically prepared enzymes
-enzymes are prescribed treatments by a provider

Question 22

describe mechanical debridement

Answer 22

-use of external physical force
-painful method
-includes wet to dry dressing, H2O2, and irrigation

Question 23

describe sharp/surgical debridement

Answer 23

-use of scalpel
-performed by physicians and advance practice nurses