pressure injury (pressure ulcer)
TRANSCRIPT
Pressure Injury (pressure ulcer)Med Surg: Integumentary - Skin
Pathophysiology
Damage to the skin and/or the underlying tissue over a bony prominence, common with bed-ridden clients who are not turned adequately or from amedical device (oxygen therapy)
Most common areas: • lower back & buttocks (sacrum & coccyx) • heels & ankles • hip bones • shoulder area & elbows
6 Stages of Pressure Injuries
Causes & Risks Treatments
Bed riddenIncontinencePoor nutritionDiabetic neuropathyLiver cirrhosis = Low Albumin
Assess skin & document (first 24 hours)
Nutrition: Protein & Fluids (2 - 3 L / day)
Turn every 1 - 2 hours
Albumin (norm: 3.5 - 5.0) Monitor:
Urine output 30 mL/hr or Less = Kidney Distress
Stage, Size, Color
MEMORY TRICK: Braden Scale
BS - Braden Scalemonitors for risk factorsBS - Broken Skin
Kaplan QuestionThe nurse is teaching a client with a stage 1 pressure injury on the greater trochanter of the left hip. What should be included in teaching?
Change positionsevery hour
Kaplan QuestionWhich finding contributes to
delayed wound healing in a client with a stage 3 pressure injury:
Urine output 25 mL/hr
MOST tested
ALB
UM
IN
3.5 - 5.0
Stage 1 = 1 layer of damage (epidermis) Red skin that is NON blanchable & NOT broken
Stage 2 = 2 layers of damage Open wound: affecting both the epidermis & dermis. Wound bed is red / pink & shiny or dry.
Stage 4 = 4 layers of damageExtends all the way down into muscle, bone, or tendon.
The fatty tissue is injured below the skin (dark purple, & sometimes open wound)
Stage 3 = 3 layers of damage (epidermis, dermis, & subcutaneous) Full thickness skin loss into the subcutaneous fat; wound may tunnel under the edges of the wound bed
Dermis
Epidermis
Stage 2
Dermis
Epidermis
Subcutaneoustissue
Stage 3
Muscle & bone
Subcutaneous tissue
Dermis
Epidermis
Stage 4
UnstageableEschar (black / brown)Slough (yellow stringy)
NCLEX TIP
Deep tissue
Eschar (black / brown) dead necrotic tissue EsCHARCOAL Slough (yellow stringy) Slough = skin of a chicken *These wounds need to be debrided before a stage is made
MEMORY TRICK:
MEMORY TRICK: