NURS 205 Chapter Notes - Chapter 8: Pressure Ulcer, Nursing Assessment, Granulation Tissue
23 Nov 2016
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Pressure injury: page 265-271; article: keast et al, 2006. Pressure ulcer: localized injury to skin/ underlying tissue, usually over bony prominence due to pressure or pressure in combination with shear, friction, or both. Most common site: sacrum 2nd is heels. Factors that influence: intensity (amount of p); duration (l. o. t it"s exerted on(cid:524); ability of pt"s tissue to. Don"t know if formed by tissue destruction occurring from bone outward to skin, or from epidermis tolerate the externally applied pressure. Vascular disease inward toward deeper tissue layers surrounding bony prominence. Other factors: shearing f (p exerted on skin when it adheres to bed & skin layers slide in the direction of body movement); friction (2 surfaces rubbing against each other), moisture (incontinence/ perspiration). Depends on the extent of tissue that is involved. Staged according to deepest level of tissue damage. )f slough/necrotic eschar present, can"t stage until remove by debridement: unstageable.
