Pressure Injuries Management and Assessment

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Questions and Answers

What is the primary goal of prevention for patients at risk for pressure injuries?

To prevent pressure injuries (correct)

To avoid pain management issues

To maintain skin elasticity

To enhance mobility

Which type of lighting is considered most suitable for assessing skin condition?

Dim lighting

Incandescent lighting

Natural or fluorescent lighting (correct)

Backlighted lighting

What does a blanch response indicate when palpating a pressure area?

Increased risk for infection

Decreased blood circulation

Normal blood circulation (correct)

Improved skin integrity

Which of the following areas is NOT typically considered a pressure area?

The abdomen Signup and view all the answers

What is one cause of abrasions in patients that nurses should watch for?

Pulling against sheets Signup and view all the answers

What indicates an abnormal temperature over a pressure area?

Warmer temperature than surrounding skin Signup and view all the answers

Identifying edema during an assessment involves which of the following actions?

Palpating over bony prominences with warm hands Signup and view all the answers

What can cause excoriations on a patient's skin?

Prolonged contact with body secretions Signup and view all the answers

What should a nurse do when examining an open or visibly infected area of a pressure injury?

Wear gloves during the examination Signup and view all the answers

Which measurement order is correct when assessing the size of a pressure ulcer?

Length, width, and depth Signup and view all the answers

How is the presence of undermining or sinus tracts assessed?

Using a clock face orientation with 12 o'clock at the patient's head Signup and view all the answers

What clinical sign might indicate the presence of an infection in a wound?

Erythema and warmth around the wound site Signup and view all the answers

At what Braden Scale score is an adult considered at risk for pressure injury development?

Below 18 points Signup and view all the answers

Which factor is not considered in risk assessment tools for pressure injuries?

Genetic predisposition Signup and view all the answers

What condition of the wound margins should be documented?

Integrity of the skin surrounding the wound Signup and view all the answers

What does a score of '1' in the sensory perception category of the Braden Scale indicate?

Completely limited sensitivity to discomfort Signup and view all the answers

How should the size of a pressure ulcer be documented?

By measuring length, width, and depth Signup and view all the answers

Which of the following Braden Scale subscales measures exposure to moisture?

Moisture Signup and view all the answers

What assessment should be done if a patient complains of pain at the wound site?

Reassess for clinical signs of infection and document pain Signup and view all the answers

What is the primary purpose of the Braden Scale?

To assess risk for pressure sore development Signup and view all the answers

Which condition indicates that the skin is considered 'Constantly Moist' on the Braden Scale?

Skin is kept almost constantly moist by urine or perspiration Signup and view all the answers

What score on the Norton Scale should be viewed as an indicator of risk for pressure injuries?

15 or 16 Signup and view all the answers

Which category was added to the Norton Scale in 1987?

Medications Signup and view all the answers

What is a common outcome planning goal for patients who are immobile?

To reposition every 2 hours Signup and view all the answers

Which assessment finding indicates a potential pressure injury?

Nonblanching erythema Signup and view all the answers

What should patients report regarding skin and wound alterations?

Changes in pain level and redness Signup and view all the answers

What often indicates inflammation when assessing skin temperature?

Increased temperature Signup and view all the answers

Which of the following is NOT a diagnosis problem associated with pressure injuries?

Hypertension Signup and view all the answers

When should assessment tools be utilized for patients at risk of pressure injuries?

At admission and upon condition changes Signup and view all the answers

What condition may be indicated by spongy or boggy tissue over bony prominences?

Edema Signup and view all the answers

Which patient group is particularly prone to pressure injuries over bony prominences?

Patients with spinal cord injuries relying on wheelchairs Signup and view all the answers

What is an appropriate method for assessing skin over pressure areas?

Palpation for temperature and consistency Signup and view all the answers

What is a key reason for routinely performing pressure injury risk assessments?

To increase awareness of specific risk factors Signup and view all the answers

What does a patient’s cool skin indicate during a temperature assessment?

Normal finding if compared to surrounding skin Signup and view all the answers

Study Notes

Pressure Injuries: Risk, Assessment, and Management

Prevention is key: The goal is to prevent pressure injuries, which can lead to infection, pain, decreased mobility, and prolonged treatment.
Assessment is crucial: Ensure good lighting (natural or fluorescent) and appropriate room temperature to accurately assess skin.
Inspect pressure areas for:
- Discoloration: Indicates impaired blood circulation
- Brisk capillary refill: Skin should blanch when gently pressed and return to its normal color quickly.
- Abrasions: Caused by friction against linens or bedding
- Excoriations: Caused by prolonged contact with body secretions or dampness.
Palpate skin temperature:
- Normal temperature should be consistent with surrounding skin.
- Increased temperature may indicate inflammation or trapped blood.
- Decreased temperature indicates poor blood flow.
Palpate bony prominences:
- Tissue should be firm but not hard.
- Spongy or boggy tissue indicates edema.
Pressure injury documentation: Note location, size, undermining/sinus tracts, stage, wound bed color, margins, surrounding skin integrity, signs of infection, pain, and any symptoms of systemic infection.
Risk assessment tools:
- Braden Scale: Six subscales (sensory perception, moisture, activity, mobility, nutrition, friction and shear). Score below 18 indicates risk for pressure injury development.
- Norton Scale: Categories include general physical condition, mental state, activity, mobility, and incontinence. Score of 15 or 16 suggests risk.
Diagnosis:
- Potential for impaired skin integrity
- Impaired skin integrity
- Risk of infection
- Underweight
- Potential for compromised dignity
- Situational low self-esteem
Planning:
- Collaborate with the patient and caregivers to develop outcomes.
- Reposition immobile patients every 2 hours and use positioning devices.
- Encourage mobile patients to maintain or improve activity levels.
- Educate patients on reporting skin changes, maintaining nutrition and hydration, and tissue protection measures.
Lifespan considerations: Older patients may have increased risk due to skin thinning and reduced mobility. Those with spinal cord injuries and wheelchair dependence are prone to pressure injuries over pelvic areas.

Pressure Area Assessment: Normal vs. Abnormal Findings

Pressure Area Assessment:
- Normal: Skin over pressure areas should be intact with brisk capillary refill.
- Abnormal: Nonblanching erythema, abrasions, excoriations.
Skin Temperature Assessment:
- Normal: Temperature should be the same as surrounding skin.
- Abnormal: Increased temperature indicates inflammation or trapped blood, decreased temperature may indicate poor blood flow.
Inspection of Bony Prominences:
- Normal: Skin over bony prominences should be firm but not hard.
- Abnormal: Spongy or boggy tissue indicates edema.

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Description

This quiz covers the essential aspects of pressure injuries, focusing on risk factors, assessment techniques, and effective management strategies. Learn how to properly assess skin condition and identify areas at risk for pressure injuries. Master the skills needed to prevent complications and enhance patient care.