Pressure injury

impaired tissue integrity

Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues, bone, joint, and ligaments Stage 4

Irrigating a wound

Facilitates progression from the inflammatory stage and prevents healing over an infected area

stage 4 pressure injury

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.

Risk factors

Impaired mobility Nutrition Hydration Decreased sensation Decreased cognition Impaired circulation Medications Moisture Shearing Friction Edema Fever

Impaired bed mobility

Limitation of independent movement from one bed position to another.

Impaired Wheelchair Mobility

Limitation of independent operation of wheelchair within environment.

Cold therapy

Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect - Decreases muscle tension, reduces inflammation, decreased O2 requirements, decreased bleeding, treats fever

Heat therapy

Promotes vasodilation, brings oxygen and wbc to wound, aids in healing, promotes delivery of nutrients, promotes relaxation

Wound Labs

WBC leukocytes Serum protein Serum albumin 3.2-5.2 Prealbumin 12-42 Erythrocytes sedimentation rate Wound culture

Primary dressing

Wound covering that comes into direct contact with the wound bed

secondary dressing

Wound dressing placed over the primary dressing that provides increased protection, cushioning, absorption, and/or occlusion.

reactive hyperemia

a bright red flush on the skin occurring after pressure is relieved

wet to dry dressing

a saturated dressing that is wrapped around a wound and left to dry. upon removal the dressing pulls away tissue debris and drainage making it a useful tool in debridement

Impaired skin integrity

altered epidermis and/or dermis, stage 1 or 2

unstageable pressure ulcer

base of ulcer covered by slough and/or eschar in the wound bed.

stage 3 pressure injury

full thickness tissue loss with visible fat

sterile water

hypotonic, water toxicity can occur

normal saline

isotonic solution, must use within 24 hours

Impaired physical mobility

limitation in independent, purposeful physical movement of the body or of one or more extremities

Moist wound healing

maintaining a moist wound environment by using an occlusive or semi occlusive primary bandage layer

stage 1 pressure injury

non-blanchable erythema of intact skin

stage 2 pressure injury

partial thickness skin loss with exposed dermis

Debriding

removal of tissue and foreign material to aid healing

Braden Scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear