Nursing: Unit 5: Chapter 36: Pressure Injuries

Bony Prominence

An area where the bone sticks out or projects from the flat surface of the body; a pressure point

Intact Skin

Normal skin and skin layers without damage or breaks

Pressure Injury

Localized damage to the skin and underlying soft tissue; the injury is usually over a bony prominence or related to a medical or other device and results from pressure or pressure in combination with shear

Shear

When layers of the skin rub against each other; when the skin remains in place and underlying tissue move and stretch, tearing underlying capillaries and blood vessels and causing tissue damage

Ulcer

A shallow or deep crater-like sore of the skin or mucous membrane

National Pressure Injury Advisory Panel

NPIAP Stands for

Back of head, shoulder blades, elbows, hips, spine, scarum, knees, ankles, heels, toes

Examples of bone prominence (10)

HSEHSSKAKT

Pressure and shearing

These two are the major causes of pressure injuries

2-6 Hours

A person can develop a pressure injury within ______ after the onset of pressure

Medical Device related pressure injuries

These type pf injuries can develop at sites where devices are used for diagnostic or treatment purposes like eyeglasses and oxygen tubing

Mucosal membrane pressure injuries

These types of injuries are found in mucous membranes where a medical device is used like a urinary catheter

abdominal, legs, buttocks, thighs, breasts

Pressure injuries can occur where skin has contact with skin like between ____ folds, the ____, the _____, the _____, and under the ______.

Erythema

This means red or redness

Blanch

This means to become white

Blanchable

This means when pressure is applied to the skin, blood is pressued away which causes the skin to become white or pale, and when relieved, the skin returns to its normal color

Non-blanchable

This is when the skin does not become white or pale when pressure is applied and removed.

Slough

This is dead tissue that is shed from the skin; it is usually light colored, soft, and moist, and may be stringy at times

Eschar

This is thick, leathery dead tissue that may be loose or adhered to the skin and is often black or brown.

1-2 Hours

Reposition bedfast persons at least ______ in order to prevent pressure injuries

hour, 15

Reposition chairfast persons at least every _____, but some persons may need to be repositioned every ____ minutes

30-degree lateral position

When preventing pressure injuries, a ________ is recomended

donut shaped

Do not let the person sit in a ______ cushion in order to prevent pressure injuries

30 degrees

Do not raise the head of the bed more than _____ to prevent pressure injuries

Bed cradle

This is a metal frame placed on the bed and over the person. Top linens are brought over the cradle to prevent pressure on the legs, feet, and toes.

Heel Elevators

These raise the heels and feet off of the bed in order to prevent pressure. Some also prevent footdrop

Elbow and heel protectors

These devices are made of foam padding, pressure relieving gel, sheepskin, or other cushioning materials that fit the shape.

Gel or fluid filled pads and cushions

These devices have a pressure relieving gel or fluid and are used for chairs and wheelchairs to prevent pressure. If the outer case is vinyl, the device may be placed in a fabric cover to protect the skin

Special Beds

Some beds have air flowing through the mattress. An alternating pressure mattress has many tubes that fill and release air at certain times.

Osteomyelitis

This is a risk if the pressure injury is over a bony prominence