Risk Factors
Name three risk factors for developing pressure ulcers.
What is obesity, poor nutrition, prior skin ulcers, dehydration, sensory impairment, smoking, immobility
A losss of tissue integrity, caused when skin and soft tissue are compressed between a bony prominence and an external surface.
What is a pressure injury?
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear.
What is suspected Deep Tissue Injury
Used on patient's with pressure areas on the coccyx or risk for injury when getting out of bed to chair
What is a pressure redistribution chair cushion?
An effective intervention to prevent skin breakdown of the heels.
What is floating the heels? (suspension off the mattress)
Most common risk factor in pressure ulcer development.
What is Immobility?
Mechanical forces that are causative agents.
What are friction and shear?
Partial thickness skin loss involving epidermis and/or dermis, the ulcer is superficial presenting as a abrasion, blister, or shallow crater
What is Stage 2
When patient's are incontinent of stool this is used as a skin protective barrier
What is a moisture barrier ointment?
Patients at nutritional risk should be offered this, with or between meals.
What is a high protein supplement?
Official term for inflammation or skin erosion caused by prolonged exposure to a sources of moisture.
What is Moisture-associated skin damage? (MASD)
pale pink to beefy red in color, this tissue is decribed as moist and slightly spongy.
What is granulation tissue?
Full thickness skin loss with extensive destruction, tissure necrosis, or damage involving muscle.
What is Stage 4
Can be made of foams or gels. Can also be fluid or air filled and can be dynamic or static.
What are pressure relieving support surfaces? (beds)
By frequently repositioning patient you can decrease the occurrence of pressure ulcer on which three high risk pressure points?
What is heel, sacrum, hips, knee, occipital, buttocks
Parallel frictional force that occurs as patients are dragged during repositioning as opposed to being lifted and moved.
What is shearing
Inflammation of the skin and subcutaneous tissue extending beyond the area of injury.
What is cellulitis?
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not throught, underlying fascia.
What is Stage 3
What blood work should be assessed to determine nutritional status?
What is albumen level, or pre-albumen level?
Name an area that may require psychosocial assessment before discharge.
What are risk factors for nutritonal deficit?
"Hidden" wounds that extend from the primary wound into the surrounding tissue.
What is tunneling?
Full thickness tissue loss where the base of the ulcer is covered with slough and or eschar in the wound bed.
What is Unstageable
These are the two available patient tools used to identify patients at greatest risk for pressure injuries.
What are the Braden and Norton Scales?
Name 3 important specialist fields to include in collaboration of pressure ulcer prevention and care.
What are social work, discharge coodinator, nutrition, wound ostomy continence nurse, infectious disease, PT and OT, Surgery