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Pressure Injury 예방 | 마이메르시 MyMerci
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Pressure Injury 예방

NCLEX Review Guide: Pressure Injury Prevention

Pressure Injury Fundamentals

Definition and Stages

  • Pressure injury is localized damage to skin and underlying tissue over a bony prominence due to sustained pressure, shear, friction, or combination of these factors.
  • Staging ranges from Stage 1 (non-blanchable erythema) to Stage 4 (full-thickness tissue loss) with additional categories for unstageable and deep tissue injuries.

Memory Aid: Pressure Injury Stages

"Red, Partial, Full, Bone"

  • Stage 1: Red - intact skin with non-blanchable redness
  • Stage 2: Partial - partial-thickness skin loss
  • Stage 3: Full - full-thickness skin loss
  • Stage 4: Bone - exposed bone, tendon, or muscle

Key Points

  • Never massage reddened areas - this can cause further tissue damage
  • Pressure injuries can develop in as little as 2 hours of sustained pressure
  • Prevention is always more cost-effective than treatment

Risk Assessment and Prevention Strategies

High-Risk Factors

  • Immobility, malnutrition, incontinence, altered sensation, and advanced age are primary risk factors that significantly increase pressure injury development.
  • Patients with Braden Scale scores ≤18 require immediate intervention and frequent repositioning every 2 hours or less.

Braden Scale vs Norton Scale

Braden ScaleNorton Scale
6 categories, score 6-235 categories, score 5-20
Lower scores = higher riskLower scores = higher risk
Risk: ≤18Risk: ≤14
  1. Assess skin integrity - Inspect all bony prominences during each shift
  2. Reposition frequently - Every 2 hours for bed-bound, every hour for chair-bound
  3. Use pressure-redistributing surfaces - Foam, air, or gel mattresses
  4. Maintain skin hygiene - Keep skin clean and dry, moisturize appropriately
  5. Optimize nutrition - Ensure adequate protein, calories, and hydration

Key Points

  • 30-degree lateral positioning reduces pressure on bony prominences better than 90-degree side-lying
  • Heel elevation devices should completely offload the heel from the bed surface

Clinical Scenarios and Interventions

Case Study

Scenario: 78-year-old patient admitted with hip fracture, immobilized for 3 days, develops 2cm reddened area on sacrum that doesn't blanch.

Priority Interventions:

  • Document as Stage 1 pressure injury
  • Implement turning schedule every 2 hours
  • Apply transparent dressing to protect area
  • Consult wound care specialist

Memory Aid: Pressure Points

"SHOP" for common pressure points:

  • Sacrum and coccyx
  • Heels
  • Occipital area
  • Pressure points (elbows, hips, ankles)

Key Points

  • Never use donut-shaped cushions - they increase pressure around the area
  • Skin inspection should occur with each repositioning
  • Moisture from incontinence increases friction and shear forces

Commonly Confused Concepts

Pressure vs Shear vs Friction

Force TypeMechanismExample
PressurePerpendicular force compressing tissueSitting in chair without repositioning
ShearParallel force causing tissue layers to slideSliding down in bed
FrictionResistance between two surfacesDragging patient across sheets

Common Pitfalls

  • Confusing Stage 2 pressure injuries with moisture-associated skin damage (MASD)
  • Staging unstageable wounds - never guess the stage if you can't see the wound bed
  • Using massage on reddened areas - this can worsen tissue damage

Study Tips and Quick Checks

NCLEX Success Tips

  • Always choose prevention over treatment when both options are available
  • Remember: Turn, Assess, Document, Educate (TADE)
  • Nutrition questions: Think protein for wound healing, not just calories

Quick Check - Can You Answer These?

  • ☐ What Braden Scale score indicates high risk?
  • ☐ How often should immobile patients be repositioned?
  • ☐ What's the difference between Stage 1 and Stage 2 pressure injuries?
  • ☐ Name three pressure redistribution devices
  • ☐ Why shouldn't you massage reddened areas?

Remember: You're not just memorizing facts - you're learning to protect your future patients from preventable harm. Every pressure injury prevented is a victory for quality nursing care! 💪

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