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Tissue Integrity
Break down the nursing process of Pressure Injuries
| Question | Answer |
|---|---|
| What is the pathohysiology of Pressure injuries? | - Pressure on tissues between bony prominance and external surface of the body cause an interuption of normal blood flow. - This will cause lack of blood and o2 to tissues. - Cause tissues to die and break down |
| What Is the risk factors of Pressure injuries? | - Immobility - Fecal/urinary incontience - Inadequate nutrion - Chronic Medical condtion - Excessive Sweating |
| What diagnostic test do you perform for Pressure injuries? | - WBC Count = look for presence of infection - Nutrional Parameter = adequate nutrion is needed for wound healing - Evaluation of erythrocyte sedimentation = determing the presce of osteomyelitis (swelling/inflamation in the bone) |
| How do we assess for Pressure injuries? | - Inspect pressure areas for discoloration, abrasion, excoriation - Palpate surface tempature of the skin - Palpate over bony prominaces |
| If a pressure injury is present, what do we assess? | - Locate the injury to a bony prominace - Measure length, width, and depth of ulcer - stage of injury - color of wound and location of necrosis / eschar - presence of undermining - conditon of wound margins |
| What are the assement tools used to predict pressure injury risk? | - Braden Scale for Predicting Pressure Sore Risk - The Norton Scale for pressure area risk assessment |
| Braden Scale assess for what risks? What are the points? | assess for: sensory perception, moisture, activity, mobility, nutrition, and friction and shear total points: 23 points Cosider a risk: <18 points |
| Norton Scale assess for what riks? What are the points | asses for: physical condition, mental state, activity, mobility, and incontinence total points: 24 consider as an indicator: 15-16 points |
| What are preventive measures for pressure injuries? | - Lifting and moving technique - Patient Positioning - Hydration & Nutrition - Moisture Management |
| How do you treat Pressure injuries? | - Wound care products - clean ulcer / surgical debridement - assess and treat for infection - preventive intervetions |
| Implemention: What do you assess? | Conduct a skin inspection at least once a day to see any sign of infection, more pressure injuries, if the wound is healing |
| Implementation: How can we keep the skin mositure free? | Clean skin at the time of soiling and at intervals |
| Implementation: How can you relieve pressure on the bony prominances? | Uses devices to relieve pressure on heels, back, elbows > use pillows and wedges |
| Implementation: What should avoid when dealing with a patient | avoid laying the patient on there side because the trochantetr is the greatest risk for pressure injuries |
| implementation: Teach patient.... | - the importance of skin hygiene - how to maintain proper nutrition - how to clean wounds - how to recognize early stages of injury and to report that right away |
| Skin Prep Guarlex (Stage 1 Wound product) | Toughens intact skin and preserves skin inegrity by preventing skin breakdown, increase blood supply, add moisture, and have trypsin which help remove necrotic tissue |
| Hydrocolloidal (Duoderm)Dressing [Stage 1/2 wound product] | - Prevents skin breakdown and promotes healing without the formation of a crust over the ulcer - permeable to air and water vapor - prevents the growth of anaerobic organisms |
| Transparent (Tegaderm) Dressing [Stage 1/2 wound product] | - Prevents skin breakdown - prevents entrance of moisture and bacteria - allows oxygen and moisture vapor permeability |
| Proteolytic Enzyesm (elase) [Stage 2 wound product] | Serve as debriding agents in inflamed and infected lesions |
| Vacuum-assisted closure (VAC) [Stage 2 wound product] | - Creates a negative pressure to help reduce edema - increase blood supply and oxygenation - decrease bacterial colonization - helps promote moist wound healing and the formation of granulation tissue |
Created by:
selena340
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