Transcription of Pressure Injury (pressure ulcer)
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Pressure Injury (pressure ulcer)
Pressure Injury ( Pressure ulcer) Med Surg: Integumentary - SkinPathophysiologyDamage 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 & elbows6 Stages of Pressure InjuriesCauses & RisksTreatmentsBed riddenIncontinencePoor nutritionDiabetic neuropathyLiver cirrhosis = Low AlbuminAssess skin & document (first 24 hours)Nutrition: Protein & Fluids (2 - 3 L / day) Turn every 1 - 2 hoursAlbumin (norm: - ) Monitor:Urine output 30 mL/hr or Less = Kidney DistressStage, Size, Color MEMORY TRICK: Braden ScaleBS - 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?
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)
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