Risk Factors
Name any three risk factors for PI development.
Immobility, Incontinence, Malnutrition, Age, Underlying conditions
Skin damage caused by prolonged pressure, shear, friction, or moisture on the skin can result in?
A Pressure Injury
Describe a stage 1 Pressure Injury
stage 1: non-blanchable erythema of intact skin
Are pressure injuries preventable?
Yes
The skin should be massaged over bony prominences. True of False
False
Why is age a risk factor?
Reduced tensile strength, reduced elasticity, dry skin, reduced adipose tissue.
Name the 4 causes if pressure injuries
Pressure, shear, friction and moisture.
Describe a stage 2 pressure injury
stage 2: partial thickness skin loss with exposed dermis
The single most important preventative measure
Offloading/repositioning
Wounds should be cleaned with Dettol
NO!!!
Prolonged exposure to moisture causes this
MASD - Moisture Associated skin damage
A patient has a pressure injury that has skin breakdown with slough and eschar present and no appearance of muscle or bone. What stage is this pressure injury?
Unstageable pressure injury
Describe a Stage 3 Pressure Injury
stage 3: full thickness skin loss; visible adipose tissue (fat)
What can be used for prevention?
Offloading devices, Position changes, Prophylactic dressings, Protecting skin integrity.
If a patient only has a red discoloration over the sacral area, position change or offloading is not necessary.
Any red discoloration should be inspected, reported, and offloaded immediately.
Immobility is a risk factor for this
Pressure damage
A patient has a pressure injury. Upon assessment of the wound, the nurse notes that bone and tendon are visible. What stage pressure injury is this?
Correct Answer: Stage 4
Describe a stage 4 Pressure Injury
stage 4: full-thickness skin and tissue loss; visible muscle and bone
Does skin treatment form part of prevention?
Yes
A nurse goes to change the dressing on a patient’s wound. She applies gloves without washing her hands, why is this a risk for infection?
Handwashing can assist in preventing cross-contamination and infection.
Malnutrition contribute to this
Increased risk of PI development
This term describes the evaluation of the tissue present on the wound bed.
Wound assessment
Black or brown tissue on the wound is?
eschar
Regular inspection of the offloading surface is required? T/F
True
This error occurs when a healthcare provider neglects to inquire about patient allergies before applying a dressing.
Risk for potential allergic reactions