Key Terms
The pressure wound that involves the epidermis and/or dermis but does not extend below the level of the dermis, it is shallow and superficial.
What is stage 2 pressure injury?
Injuries causes by oxygen tubing, a nasogastric [NG] tube, oxygen sensor probes, a continuous positive airway pressure [CPAP] mask, or trach ties
What is medical device–related pressure injuries?
Pressure injuries with eschar.
What is unstageable pressure injury?
Should occur on every patient upon admission, on every shift, with transfer of the patient to another unit or facility, and when the patient is discharged
what is skin assessment.
Necrotic tissue in the wound bed that makes it impossible to assess the depth of the wound or the involvement of underlying structures.
What is eschar?
Risk group due to unable to feel pain, unable to respond appropriately, or limited in their ability to move or maintain their position independently.
What is sensory loss or immobility?
Undermining and tunneling are present
What is stage 3?
Drainage that indicates bleeding and is bright red
what is sanguineous?
An area of intact skin that is purple or maroon or a blood-filled blister.
What is suspected deep-tissue pressur injury?
A thorough nutritional assessment, including an evaluation of weight and recent changes in weight, BMI, diet history, and pertinent laboratory findings.
What is the essential first step in preventing the development of pressure injuries?
skin has abnormal reactive hypermia and does not blanch
ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear
What is Braden scale?
Tissue healed from injury but will never the same as before the injury.
What is healed stage #.
Inflammation or skin erosion caused by the prolonged exposure to a source of moisture (such as urine, stool, sweat, wound drainage, saliva, or mucus).
What is moisture-associated skin damage (MASD)?
Shallow and superficial with a pink wound bed, sometimes with blister.
Whar is stage 2 pressure injury?
a focused wound assessment includes?
what is an evaluation of the wound’s location, size, and color; presence of drainage; con- dition of the wound edges; characteristics of the wound bed; and patient’s response to the wound or wound treatment
An area of tissue loss present under intact skin, usually along the edges of the wound forming a lip
What is undermining?
The phenomenon resulted from the relationship of friction and gravity.
What is shear?
What is stage 4 pressure injury?
what diseases affect would healing
what is comorbid conditions such as diabetes and heart disease, obesity, poor nutrition, advanced age