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
