Wound Care- Chapter 6
What is the most common type of wound?
Pressure injury
Pressure injuries most commonly in the ______________ and patients with a
______.
Elderly; SCI
_____________ ___________ involves a localized damage to the skin and/or
underlying soft tissue usually over a bony prominence or related to a medical or
other device (oxygen canules, wheelchair)
Pressure injury
Pressure injuries can occur from intense and/or prolonged ______________.
Pressure
Pressure injuries can occur from pressure in combination with ___________
Shear
5 things pressure and shear can be impacted by
Microclimate (temp/bedding), nutrition, perfusion, comorbidities, and condition of
tissue
Pressure injuries can occur in ______ healthcare settings but are most coming in
______-________ care facilities and the ______.
All; long-term; ICU
T/F: All pressure injuries are avoidable
False (weak skin integrity/terminally ill pt, skin failure)
Primary cause of pressure injuries
Immobility
_________,____________, and _________ also impact tissue damage and skin
breakdown
Moisture, friction, shear
Moisture leading to skin leading to skin breakdown is defined as __________ fluid
against the skin
Excess
Reason you could have excess moisture on the skin (4)
Incontinence, wound drainage, excessive perspiration, Maceration
____________ is caused by two surfaces rubbing against each other
Friction
Friction causes the epidermis to be damaged and causes a decrease in
____________ and _____________ of the skin
Strength; integrity
Friction can cause possible shear in ________layers of tissue
Deep
__________ distorts both superficial and deep tissue damaging capillaries
Shear
Shear forces damaging capillaries leads to tissue __________ and tissue
__________.
, Anoxia; necrosis
Shearing effects more of the ______________ surfaces and can cause blood flow to
get cut off- which is _____________.
Deeper; necrosis
Would shear/friction occur from rubbing the heals on the bed?
Friction
__________ ______________ is blanchable erythema or redness
Tissue hyperemia
Tissue hyperemia can occur after ______ min.
30
Tissue hyperemia takes _____ hour to recover if pressure is relieved.
1
__________ _____________ is characterized by deeper redness with damage of
underlying tissue
Tissue ischemia
Tissue ischemia occurs from ___-____ hrs of unrelieved pressure
2-6
Tissue ischemia recovers after _____ hrs if pressure is relieved
36
___________ is characterized by destruction of tissue
Necrosis
Necrosis occurs from >____ hrs of unrelieved pressure
6
Reversal of tissue necrosis may or may not occur depending on the patients clinical
__________________ and their ____________ _____________.
Comorbities; healing potential
Tissue damage is dependent upon the ________ and ____________ of exposure to
the mechanical forces.
Time; intensity
High pressure requires a ___________ amount of time to cause damage
Short
Low pressure requires a _____________ amount of time to cause damage
Longer
The _____________ scale evaluates a pt risk of developing a pressure injury
Braden
____ is the highest score you can get on the Braden scale
23
____ is the lowest score you can get on the Braden scale
18
If a patient scores lower than 18 on the Braden scale they are at _______ risk of
developing a pressure injury
High
If a pt has a status change, you need to _______ the Braden scale
Redo
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