Pressure injury staging, wound dressing selection, and wound healing phase concepts for the bedside nurse.
35 cards · basic cards · AI-written, checked twice. Edit anything.
- What defines a Stage 1 pressure injury?
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Intact skin with non-blanchable erythema (redness that does not turn white with pressure).- What defines a Stage 2 pressure injury?
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Partial-thickness skin loss with exposed dermis, seen as a shallow open ulcer or an intact/ruptured blister.- What defines a Stage 3 pressure injury?
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Full-thickness skin loss with visible fat, but no exposed bone, tendon, or muscle.- What defines a Stage 4 pressure injury?
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Full-thickness skin and tissue loss with exposed bone, tendon, or muscle.- What defines an unstageable pressure injury?
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Full-thickness skin and tissue loss where the wound base is covered by slough or eschar, so true depth cannot be determined.- What defines a deep tissue pressure injury (DTPI)?
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Persistent, non-blanchable deep red, maroon, or purple discoloration from underlying soft tissue damage.- How does non-blanchable erythema differ from blanchable erythema during a skin check?
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Non-blanchable erythema stays red when pressed; blanchable erythema turns pale under pressure and refills after release.- Name common sites for pressure injuries in a bedbound patient.
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Sacrum, heels, and ischial tuberosities (also occiput and elbows).- What is the Braden Scale used for?
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Assessing a patient's risk for developing a pressure injury.- Name the six subscales of the Braden Scale.
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Sensory perception, moisture, activity, mobility, nutrition, and friction/shear.- How often should an at-risk, immobile patient be repositioned to prevent pressure injuries?
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At least every 2 hours.- Why should stable, dry, intact eschar on a heel usually not be debrided?
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It acts as the body's own protective covering over the wound; removing it increases infection risk.- What is slough in wound assessment?
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Yellow, moist, stringy nonviable (dead) tissue in the wound bed.- What is eschar in wound assessment?
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Thick, black or brown necrotic (dead) tissue in the wound bed.- When is a hydrocolloid dressing an appropriate choice?
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For wounds with light to moderate exudate, to support autolytic debridement and keep a moist healing environment.
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