Risk Factors
Name three risk factors for developing pressure ulcers.
What is obesity, poor nutrition, prior skin ulcers, dehydration sensory impairment, smoking
Pressure injuries develop as a result of tissue anoxia which is due to the force or weight against the capillaries, also known as
What is intensity of pressure
•Obstruction of capillary blood flow by externally applied pressure creates this
What is tissue ischemia--hypoxia
This preventative measure helps prevent pressure injury development when there is extreme moisture
What is moisture management
When patients are incontinent of urine this is used as a protective barrier.
What is aloe vesta
Greatest risk factor for the pressure ulcer development.
What is Immobility
Pressure injuries also develop as a result of low-intensity pressures over a long time, or high-intensity pressures over a short time. This is known as
What is Duration of Pressure.
•If pressure is removed in a short period, blood flow returns & skin appears to flush known as:
What is reactive hyperemia
When patients are incontinent of stool this is used as a skin protective barrier
What is Sensi-Care
When preventing pressure injury development, what are 3 items that should not be used?
What are foam cutouts, waffle cushions, donut devices
Immobility for what time frame can cause tissue ischemia?
What is 20 minutes
This is influenced by the ability of the skin and underlying structures to work together as a set of parallel springs, that transmit the load from the surface of the tissue to the skeleton inside.
What is tissue tolerance
An area of redness that becomes white when compressed with a finger.
What is Blanching Erythema
For prevention, the frequency of repositioning the SCI Veteran should be
What is every two hours and prn
By frequently repositioning the SCI patient, you can prevent pressure injury development on these two most highly susceptible areas
What is the sacrum and the heels
Parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
This is known as a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or of pressure in combination with friction and/or shear.
What is a Pressure Injury
An area of redness on the skin is known as
What is erythema
Minimizing linen layers is important. Evidence states that the layers of linen should be
What is no more than 2 layers
Which intervention should be recommended for offloading heels?
What is use pillows
For what two comorbidities does the risk of mortality increase for the person with a spinal cord injury by 1.4-2 fold, respectively
What is diabetes mellitus and congestive heart failure
These 3 extrinsic factors contribute to the development of a Pressure Injury
What is Friction, Moisture, and Shear
This effect indicates that deep pressure ulcers form at the bone-soft tissue interface not at the surface of the skin
What is the McClemont Effect
For a Veteran at risk for pressure injury development, the head of the bed should be minimized to what level
What is 30 degrees or less
All SCI Veterans, particularly the taller Veterans should be monitored closely to make sure the feet are not pressed or resting
What is against the footboard of the bed.