Exam 3 Study Guide
Risk Factors for pressure injuries
o Intensity of pressure
Capillary closing pressure and critical closing pressure refer to
the minimum pressure required to collapse a capillary. Pressure
is 12 to 32 mm Hg. Subcutaneous and muscle tissues are more
susceptible to to the effects of pressure than other tissues
o Duration of pressure
Low levels of pressure over long periods of time can be as
damaging as high levels of pressure
o Medical Devices
Oxygen tubing, NG tubes, O2 sensor probes, CPAP are all at risk
for medical device-related pressure injuries.
Anyone with medical devices is at risk, especially those in acute
care, critical care, long-term care, and home care
Assess to ensure the device is not too tight, if possible, place
prophylactic dressing under the device
CARE Choose a size-appropriate device, Assess the skin under
the medical device, Reposition and reapply the device, using
padding, if necessary, empowered to evaluate daily
discontinuation
o Friction and Shear
Friction is the rubbing of two surfaces together such as skin and
the bed, it damages the epidermal layer
Shear is hyperangulation and stretching the capillaries,
damaging them and the ability to transport blood, significantly
contributes to the development of pressure injuries, particularly
the sacrum and coccyx
o Sensory loss or immobility
Patients with neurological conditions and those with chronic
conditions that lead to neuropathies are unable to reposition
themselves independently
o Moisture
Moisture-associated skin damage (MASD) is the general term for
inflammation or skin erosion caused by prolonged exposure to a
source of moisture
Incontinence is thought to contribute to pressure injuries due to
the effects of maceration (softening of the skin due to moisture),
but it is confined to the more superficial layers
o Nutrition
Inadequate nutrition is implicated in the development of
pressure injuries, deficiencies in vitamin A,C, and E and the
minerals zinc and copper and protein-calorie malnutrition
decreases the skins ability to withstand pressure
, A nutritional assessment, including weight and recent changes,
BMI, diet history, consultation with a dietician, and lab findings
are the first step in prevention
The elderly population is at an increased risk because they are
slower to heal, have comorbidities, medication use, exposure to
the sun, and skin changes due to aging
Characteristics in stages of wounds
o Stage 1: Non blanchable Erythema of intact skin
Intact, nonblistered skin with non-blanchable erythema or
persistent redness in the area that has been exposed to
pressure. The redness is called abnormal reactive hyperemia
Due to being harder to visualize in darker toned patients, you
can also assess for pain and if the skin is softer or firmer than
surrounding tissue, as well as temperature
o Stage 2: Partial-thickness skin loss with exposed dermis
Involves the epidermis and/or dermis but does not extend past
the dermis
Shallow and superficial with a pink wound bed. Intact or
ruptured blisters are the result of pressure and are considered
stage 2
o Stage 3: Full-thickness skin loss
Extend into the subcutaneous tissue but do not extend through
the fascia to the muscle
Undermining or tunneling/sinus tract may be present
Degree of depth is dependent on the location
o Stage 4: full-thickness skin and tissue loss
Deeper than a stage 3, involves exposure of muscle, bone, or
connective tissue
o Unstageable: Obscured full thickness skin and tissue loss
Has necrotic tissue (eschar) in the wound bed making it
impossible to assess the depth without debridement
o Deep-tissue: persistent non blanchable deep-red, maroon, or purple
discoloration
An area of intact skin that is purple or maroon or a blood-filled
blister
o Healing
As an injury heals it does not go backwards.
Ex: A stage 4 wound does not go to a stage 3, but would be
described as a healed stage 4
Phases of wound healing and complications
o Inflammatory phase
Initial response to wounding of the skin, lasts about 3 days. With
initial injury bleeding occurs, which triggers the coagulation
cascade
o Proliferative phase
, Repair of the defect, filling in the wound bed with new tissue and
resurfacing the wound
Lasts several weeks, but can be shorter with a surgically closed
wound
Development of new blood vessels that are needed to support
new tissue, collagen synthesis, wound contraction and
epithelialization
Granulation tissue is the new tissue created to fill the wound,
beefy red in appearance, bleeds easily, has a bumpy texture
o Maturation phase
Last phase of wound healing, can last up to a year, remodeling
phase, scar tissue is formed and strengthened, never 100% of
original strength, only 80%
o Dehiscence
Is partial or complete separation of the tissue layers of a surgical
incision during the healing phase
o Evisceration
Total separation of the tissue layers, allowing underlying organs
to push through the incision
o Dehiscence and evisceration usually occur 5 to 9 days after surgery.
Interventions include teaching the patient to splint the incision while
coughing or deep breathing
o If dehiscence or evisceration occur cover the wound with gauze that is
moistened with normal sterile saline and notify the physician
immediately
Wound Healing Intentions
o Primary intention
Wounds that can be approximated (brought together)
Progress through phases of wound healing rapidly, and
uncomplicated
Labeled acute wounds, Surgical incisions, traumatic wounds,
minimal scar formation
o Secondary intention
Chronic wounds that fail to progress healing in a timely manner,
remain open for an extended period
When healing new tissue must fill in from the bottom and sides
of the wound until the wound bed is filled
o Tertiary intention
When a delay occurs between injury and closure
Drains
o Closed Drainage Systems
Jackson-Pratt & Hemovac
Orthopedic and abdominal surgical patients
Usually disconnected 3-5 days after surgery
Use a graduated measuring device to measure drainage
Empty every 4 to 8 hours
Risk Factors for pressure injuries
o Intensity of pressure
Capillary closing pressure and critical closing pressure refer to
the minimum pressure required to collapse a capillary. Pressure
is 12 to 32 mm Hg. Subcutaneous and muscle tissues are more
susceptible to to the effects of pressure than other tissues
o Duration of pressure
Low levels of pressure over long periods of time can be as
damaging as high levels of pressure
o Medical Devices
Oxygen tubing, NG tubes, O2 sensor probes, CPAP are all at risk
for medical device-related pressure injuries.
Anyone with medical devices is at risk, especially those in acute
care, critical care, long-term care, and home care
Assess to ensure the device is not too tight, if possible, place
prophylactic dressing under the device
CARE Choose a size-appropriate device, Assess the skin under
the medical device, Reposition and reapply the device, using
padding, if necessary, empowered to evaluate daily
discontinuation
o Friction and Shear
Friction is the rubbing of two surfaces together such as skin and
the bed, it damages the epidermal layer
Shear is hyperangulation and stretching the capillaries,
damaging them and the ability to transport blood, significantly
contributes to the development of pressure injuries, particularly
the sacrum and coccyx
o Sensory loss or immobility
Patients with neurological conditions and those with chronic
conditions that lead to neuropathies are unable to reposition
themselves independently
o Moisture
Moisture-associated skin damage (MASD) is the general term for
inflammation or skin erosion caused by prolonged exposure to a
source of moisture
Incontinence is thought to contribute to pressure injuries due to
the effects of maceration (softening of the skin due to moisture),
but it is confined to the more superficial layers
o Nutrition
Inadequate nutrition is implicated in the development of
pressure injuries, deficiencies in vitamin A,C, and E and the
minerals zinc and copper and protein-calorie malnutrition
decreases the skins ability to withstand pressure
, A nutritional assessment, including weight and recent changes,
BMI, diet history, consultation with a dietician, and lab findings
are the first step in prevention
The elderly population is at an increased risk because they are
slower to heal, have comorbidities, medication use, exposure to
the sun, and skin changes due to aging
Characteristics in stages of wounds
o Stage 1: Non blanchable Erythema of intact skin
Intact, nonblistered skin with non-blanchable erythema or
persistent redness in the area that has been exposed to
pressure. The redness is called abnormal reactive hyperemia
Due to being harder to visualize in darker toned patients, you
can also assess for pain and if the skin is softer or firmer than
surrounding tissue, as well as temperature
o Stage 2: Partial-thickness skin loss with exposed dermis
Involves the epidermis and/or dermis but does not extend past
the dermis
Shallow and superficial with a pink wound bed. Intact or
ruptured blisters are the result of pressure and are considered
stage 2
o Stage 3: Full-thickness skin loss
Extend into the subcutaneous tissue but do not extend through
the fascia to the muscle
Undermining or tunneling/sinus tract may be present
Degree of depth is dependent on the location
o Stage 4: full-thickness skin and tissue loss
Deeper than a stage 3, involves exposure of muscle, bone, or
connective tissue
o Unstageable: Obscured full thickness skin and tissue loss
Has necrotic tissue (eschar) in the wound bed making it
impossible to assess the depth without debridement
o Deep-tissue: persistent non blanchable deep-red, maroon, or purple
discoloration
An area of intact skin that is purple or maroon or a blood-filled
blister
o Healing
As an injury heals it does not go backwards.
Ex: A stage 4 wound does not go to a stage 3, but would be
described as a healed stage 4
Phases of wound healing and complications
o Inflammatory phase
Initial response to wounding of the skin, lasts about 3 days. With
initial injury bleeding occurs, which triggers the coagulation
cascade
o Proliferative phase
, Repair of the defect, filling in the wound bed with new tissue and
resurfacing the wound
Lasts several weeks, but can be shorter with a surgically closed
wound
Development of new blood vessels that are needed to support
new tissue, collagen synthesis, wound contraction and
epithelialization
Granulation tissue is the new tissue created to fill the wound,
beefy red in appearance, bleeds easily, has a bumpy texture
o Maturation phase
Last phase of wound healing, can last up to a year, remodeling
phase, scar tissue is formed and strengthened, never 100% of
original strength, only 80%
o Dehiscence
Is partial or complete separation of the tissue layers of a surgical
incision during the healing phase
o Evisceration
Total separation of the tissue layers, allowing underlying organs
to push through the incision
o Dehiscence and evisceration usually occur 5 to 9 days after surgery.
Interventions include teaching the patient to splint the incision while
coughing or deep breathing
o If dehiscence or evisceration occur cover the wound with gauze that is
moistened with normal sterile saline and notify the physician
immediately
Wound Healing Intentions
o Primary intention
Wounds that can be approximated (brought together)
Progress through phases of wound healing rapidly, and
uncomplicated
Labeled acute wounds, Surgical incisions, traumatic wounds,
minimal scar formation
o Secondary intention
Chronic wounds that fail to progress healing in a timely manner,
remain open for an extended period
When healing new tissue must fill in from the bottom and sides
of the wound until the wound bed is filled
o Tertiary intention
When a delay occurs between injury and closure
Drains
o Closed Drainage Systems
Jackson-Pratt & Hemovac
Orthopedic and abdominal surgical patients
Usually disconnected 3-5 days after surgery
Use a graduated measuring device to measure drainage
Empty every 4 to 8 hours
