Podcast
Questions and Answers
What is the primary goal of prevention for patients at risk for pressure injuries?
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?
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?
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?
Which of the following areas is NOT typically considered a pressure area?
What is one cause of abrasions in patients that nurses should watch for?
What is one cause of abrasions in patients that nurses should watch for?
What indicates an abnormal temperature over a pressure area?
What indicates an abnormal temperature over a pressure area?
Identifying edema during an assessment involves which of the following actions?
Identifying edema during an assessment involves which of the following actions?
What can cause excoriations on a patient's skin?
What can cause excoriations on a patient's skin?
What should a nurse do when examining an open or visibly infected area of a pressure injury?
What should a nurse do when examining an open or visibly infected area of a pressure injury?
Which measurement order is correct when assessing the size of a pressure ulcer?
Which measurement order is correct when assessing the size of a pressure ulcer?
How is the presence of undermining or sinus tracts assessed?
How is the presence of undermining or sinus tracts assessed?
What clinical sign might indicate the presence of an infection in a wound?
What clinical sign might indicate the presence of an infection in a wound?
At what Braden Scale score is an adult considered at risk for pressure injury development?
At what Braden Scale score is an adult considered at risk for pressure injury development?
Which factor is not considered in risk assessment tools for pressure injuries?
Which factor is not considered in risk assessment tools for pressure injuries?
What condition of the wound margins should be documented?
What condition of the wound margins should be documented?
What does a score of '1' in the sensory perception category of the Braden Scale indicate?
What does a score of '1' in the sensory perception category of the Braden Scale indicate?
How should the size of a pressure ulcer be documented?
How should the size of a pressure ulcer be documented?
Which of the following Braden Scale subscales measures exposure to moisture?
Which of the following Braden Scale subscales measures exposure to moisture?
What assessment should be done if a patient complains of pain at the wound site?
What assessment should be done if a patient complains of pain at the wound site?
What is the primary purpose of the Braden Scale?
What is the primary purpose of the Braden Scale?
Which condition indicates that the skin is considered 'Constantly Moist' on the Braden Scale?
Which condition indicates that the skin is considered 'Constantly Moist' on the Braden Scale?
What score on the Norton Scale should be viewed as an indicator of risk for pressure injuries?
What score on the Norton Scale should be viewed as an indicator of risk for pressure injuries?
Which category was added to the Norton Scale in 1987?
Which category was added to the Norton Scale in 1987?
What is a common outcome planning goal for patients who are immobile?
What is a common outcome planning goal for patients who are immobile?
Which assessment finding indicates a potential pressure injury?
Which assessment finding indicates a potential pressure injury?
What should patients report regarding skin and wound alterations?
What should patients report regarding skin and wound alterations?
What often indicates inflammation when assessing skin temperature?
What often indicates inflammation when assessing skin temperature?
Which of the following is NOT a diagnosis problem associated with pressure injuries?
Which of the following is NOT a diagnosis problem associated with pressure injuries?
When should assessment tools be utilized for patients at risk of pressure injuries?
When should assessment tools be utilized for patients at risk of pressure injuries?
What condition may be indicated by spongy or boggy tissue over bony prominences?
What condition may be indicated by spongy or boggy tissue over bony prominences?
Which patient group is particularly prone to pressure injuries over bony prominences?
Which patient group is particularly prone to pressure injuries over bony prominences?
What is an appropriate method for assessing skin over pressure areas?
What is an appropriate method for assessing skin over pressure areas?
What is a key reason for routinely performing pressure injury risk assessments?
What is a key reason for routinely performing pressure injury risk assessments?
What does a patient’s cool skin indicate during a temperature assessment?
What does a patient’s cool skin indicate during a temperature assessment?
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.
