🛏️ Swen Debaz ak Konfò · Leson 5 sou 6 · 6 min
Blesi Presyon: Klase Li, Vire Yo, Nouri Yo
Pressure Injuries: Stage It, Turn Them, Feed Them
🩹 Yon zòn wouj sou sakwòm lan ki pa blanchi lè ou peze li deja se yon blesi presyon estad 1. Lè nenpòt moun wè zo, kesyon klasman an nan egzamen an se pati fasil la.
🩹 A reddened area over the sacrum that does not blanch when you press it is already a stage 1 pressure injury. By the time anyone sees bone, the staging question on the exam is the easy part.
💡 Ide prensipal
Estad 1 woujè ki pa blanchi, 2 epesè pasyèl, 3 grès vizib, 4 zo oswa tandon vizib, pa ka klase lè li kouvri. Braden ki pi ba vle di risk ki pi wo; vire chak 2 èdtan epi pwoteje talon yo.
Stage 1 non-blanchable redness, 2 partial thickness, 3 fat visible, 4 bone or tendon visible, unstageable when covered. Lower Braden means higher risk; turn every 2 hours and protect heels.
🧠 Poukisa sa enpòtan
ESTAD 1: po entak ak woujè KI PA BLANCHI; nan po ki pi fonse, chèche chanjman koulè, chalè, fèmte oswa doulè. ESTAD 2: pèt epesè pasyèl ak yon blesi louvri fon oswa yon anpoul entak oswa ki pete, woz ak mouye, san esch. ESTAD 3: pèt epesè konplè ak grès vizib, petèt dekole; pa zo oswa tandon vizib. ESTAD 4: pèt epesè konplè ak zo, tandon oswa misk ekspoze. PA KA KLASE (UNSTAGEABLE): baz la kouvri ak esch oswa eskar kidonk pwofondè pa ka wè. Blesi TISI PWOFON: po entak oswa pa entak ak yon zòn lokalize wouj fonse, mawon oswa vyolèt ki pèsistan epi ki pa blanchi, oswa separasyon epidèmik ki revele yon kabann blesi fonse oswa yon anpoul plen san (yon anpoul plen sewòm se estad 2). Evalye risk ak echèl BRADEN (pèsepsyon sansoryèl, imidite, aktivite, mobilite, nitrisyon, friksyon ak sisayman); nòt ki pi ba vle di risk ki pi wo, ak 18 oswa pi ba konsidere kòm riske. Anpeche ak repozisyonman omwen chak 2 èdtan, sifas ki redistribye presyon, yon enklinasyon lateral 30 degre, talon ki flote lwen kabann lan, tèt kabann lan pa pi wo pase nesesè pou limite sisayman, jesyon imidite, ak ase pwoteyin ak kalori. Pa masaje zòn wouj epi pa itilize kousen ki gen fòm beye.
STAGE 1: intact skin with NON-BLANCHABLE redness; in darker skin, look for color change, warmth, firmness or pain. STAGE 2: partial-thickness loss with a shallow open wound or an intact or ruptured blister, pink and moist, no slough. STAGE 3: full-thickness loss with visible fat, possibly undermining; no bone or tendon visible. STAGE 4: full-thickness loss with exposed bone, tendon or muscle. UNSTAGEABLE: the base is covered by slough or eschar so depth cannot be seen. DEEP TISSUE injury: intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon or purple discoloration, or epidermal separation revealing a dark wound bed or a blood-filled blister (a serum-filled blister is stage 2). Assess risk with the BRADEN scale (sensory perception, moisture, activity, mobility, nutrition, friction and shear); lower scores mean higher risk, with 18 or below considered at risk. Prevent with repositioning at least every 2 hours, pressure-redistribution surfaces, a 30-degree lateral tilt, heels floated off the bed, the head of the bed no higher than needed to limit shear, moisture management, and adequate protein and calories. Do not massage reddened areas and do not use donut-shaped cushions.
🏥 Nan lavi reyèl
🦶 Yon pasyan imobil gen yon zòn 2 cm po vyolèt, entak, mou sou talon an. Yon nouvo enfimyè ekri 'estad 1'. Enfimyè ki gen eksperyans lan korije li an blesi presyon tisi pwofon, li flote talon yo sou yon zorye, epi li aranje yon konsiltasyon dyetetisyen pou move konsomasyon ak pèt pwa pasyan an. Dekolorasyon wouj fonse, mawon oswa vyolèt ki pèsistan montre blesi tisi pwofon, epi klasman deside plan blesi a.
🦶 An immobile client has a 2 cm area of purple, intact, boggy skin on the heel. A new nurse charts 'stage 1'. The experienced nurse corrects it to deep tissue pressure injury, floats the heels on a pillow, and arranges a dietitian consult for the client's poor intake and weight loss. Persistent deep red, maroon or purple discoloration points to deep tissue injury, and staging decides the wound plan.
📌 Sa pou retni
- Woujè ki pa blanchi deja se estad 1Non-blanchable redness is already stage 1
- Pa ka klase vle di kouvri ak esch oswa eskar; blesi tisi pwofon se wouj fonse, mawon oswa vyolètUnstageable means covered by slough or eschar; deep tissue injury is deep red, maroon or purple
- Braden 18 oswa pi ba: riske; vire q2h, flote talon, pwoteje kont imidite ak sisaymanBraden 18 or below: at risk; turn q2h, float heels, protect from moisture and shear
✅ Teste tèt ou
Yon blesi presyon sou koksis la montre pèt tisi epesè konplè ak grès soukutan vizib men pa zo oswa tandon ekspoze. Ki estad sa ye?A pressure injury on the coccyx shows full-thickness tissue loss with visible subcutaneous fat but no exposed bone or tendon. Which stage is this?
- Estad 2Stage 2
- Estad 4Stage 4
- Estad 3Stage 3
- Estad 1Stage 1
Repons: C · Estad 3
Grès vizib san zo, tandon oswa misk defini estad 3. Estad 4 ekspoze zo oswa tandon.
Visible fat without bone, tendon or muscle defines stage 3. Stage 4 exposes bone or tendon.
Nòt echèl Braden yon pasyan se 12. Kijan enfimyè a dwe entèprete sa?A client's Braden scale score is 12. How should the nurse interpret this?
- Risk ba; swen woutin sifiLow risk; routine care is sufficient
- Risk wo; kòmanse yon plan prevansyonHigh risk; start a prevention plan
- Nòt la pa valab epi yo dwe repete liThe score is invalid and must be repeated
- Sèlman nitrisyon bezwen atansyonOnly nutrition needs attention
Repons: B · Risk wo; kòmanse yon plan prevansyon
Nòt Braden ki pi ba vle di risk ki pi wo; 12 oswa pi ba konsidere kòm risk wo.
Lower Braden scores mean higher risk; 12 or below is considered high risk.
Ki entèvansyon ki apwopriye pou yon pasyan ki riske blesi presyon?Which intervention is appropriate for a client at risk of pressure injuries?
- Masaje zòn zo wouj pou amelyore sikilasyonMassage reddened bony areas to improve circulation
- Repozisyone chak 2 èdtan epi flote talon yoReposition every 2 hours and float the heels
- Itilize yon kousen beye pou soulaje presyon lè li chitaUse a donut cushion to relieve pressure when sitting
- Kenbe tèt kabann lan a 60 degre toutanKeep the head of the bed at 60 degrees at all times
Repons: B · Repozisyone chak 2 èdtan epi flote talon yo
Repozisyonman ak elevasyon talon soulaje presyon. Masaj domaje tisi frajil, beye kreye bag presyon, epi yon tèt kabann wo ogmante sisayman.
Repositioning and heel elevation relieve pressure. Massage damages fragile tissue, donuts create pressure rings, and a high head of bed increases shear.
Kesyon tankou NCLEX, XP ak seri jou nan aplikasyon an, an angle ak èd an kreyòl. Pa bezwen enskri.