Medical Surgical Nursing I
Pressure Injury Prevention
Localized damage to the skin and underlying soft tissue usually over a bony prominence as a result of intense or prolonged pressure.
Risk Assessment
- Use Braden Scale for risk scoring
- Monitor skin for non-blanchable redness
- Assess nutritional status (albumin/protein)
Interventions
- Reposition every 2 hours
- Utilize pressure-relieving support surfaces
- Keep skin clean and dry
- Keep heels off the bed
Staging Basics
- Stage 1: Non-blanchable erythema
- Stage 2: Partial thickness loss
- Stage 3: Full thickness loss
- Stage 4: Full thickness skin and tissue loss
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