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 a medical 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 ridden Inconnence Poor nutrion Diabec neuropathy Liver cirrhosis = Low Albumin Assess skin & document (first 24 hours) Nutrion: 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 Scale monitors for risk factors BS - Broken Skin Kaplan Queson The nurse is teaching a client with a stage 1 pressure injury on the greater trochanter of the leﬅ hip. What should be included in teaching? Change posions every hour Kaplan Queson Which finding contributes to delayed wound healing in a client with a stage 3 pressure injury: Urine output 25 mL/hr MOST tested ALBUMIN 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 damage Extends 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 Subcutaneous ssue Stage 3 Muscle & bone Subcutaneous ssue Dermis Epidermis Stage 4 Unstageable Eschar (black / brown) Slough (yellow stringy) NCLEX TIP Deep ssue 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:

Pressure Injury (pressure ulcer)

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Page 1: Pressure Injury (pressure ulcer)

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

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: