Pressure Injuries: Staging and Management

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Questions and Answers

What is a characteristic manifestation of Stage 1 pressure injuries?

Blood-filled blisters on the fingers

Dark, discolored skin with pus-filled blisters

Nonblanchable erythema of intact skin (correct)

Intact skin with localized maroon discoloration

What symptom may indicate a Deep Tissue Pressure Injury?

Blisters filled with clear fluid

Pink tissue with some discoloration

Thin eschar on a dark wound bed (correct)

Localized, nonblanchable maroon discoloration

In which situation can identification of pressure injuries be particularly challenging?

In patients with darkly pigmented skin (correct)

In patients receiving anticoagulant therapy

In patients with normal skin pigmentation

In patients with a history of skin cancer

What may precede a Deep Tissue Pressure Injury?

Painful tissue with different temperature and consistency Signup and view all the answers

What is NOT a description of Stage 1 pressure injuries?

Presence of pus and blisters Signup and view all the answers

What characterizes a Stage 1 pressure injury?

Intact skin with nonblanchable erythema Signup and view all the answers

Which treatment is NOT appropriate for a Stage 2 pressure injury?

Surgical removal of necrotic tissue Signup and view all the answers

In pressure injuries, which tissue is usually the least resistant to pressure?

Muscle Signup and view all the answers

What is a common manifestation of a deep tissue pressure injury?

Intact skin with localized purple discoloration Signup and view all the answers

Which of the following is a key intervention for managing all stages of pressure injuries?

Frequent repositioning Signup and view all the answers

What does the presence of slough or eschar indicate in pressure injuries?

Full-thickness tissue loss Signup and view all the answers

What treatment is recommended for a Stage 1 pressure injury?

Cleansing of the ulcer and surrounding area Signup and view all the answers

What does necrotic tissue require in the treatment of Stage 3 or Stage 4 pressure injuries?

Surgical removal Signup and view all the answers

What factor contributes to the varying manifestations of pressure injuries?

Resistance of soft tissue to pressure Signup and view all the answers

Which statement is true regarding the distribution of pressure on bony prominences?

Pressure decreases gradually from the bony area towards the periphery. Signup and view all the answers

What is the primary objective for patients at risk for developing pressure injuries?

Prevention of pressure injury development Signup and view all the answers

Which diagnostic test is particularly useful for determining the presence of osteomyelitis?

Erythrocyte sedimentation rate (ESR) Signup and view all the answers

What is the purpose of surgical debridement in the treatment of pressure injuries?

To remove nonviable tissue before healing Signup and view all the answers

Which of the following types of debridement utilizes the body's own enzymes?

Autolytic debridement Signup and view all the answers

What healthcare team member's action is crucial to preventing pressure injuries?

Regular patient assessment and repositioning Signup and view all the answers

Which of the following lab studies should be included to assess a patient's nutritional status for wound healing?

Albumin levels Signup and view all the answers

Which dressing type supports the body's natural enzymes for debridement?

Hydrocolloid dressings Signup and view all the answers

What is a benefit of using maggot therapy for wound debridement?

It causes minimal damage to healthy surrounding tissues. Signup and view all the answers

What should be regularly assessed when ulcers develop in patients?

Changes in staging of the ulcers Signup and view all the answers

Which of the following describes a function of the secretions from fly larvae?

They break down necrotic tissue while preserving healthy tissue. Signup and view all the answers

What type of dressing is preferred for deep, exudative wounds?

Alginate dressings Signup and view all the answers

What important role does the presence of maggots play in wound healing?

They stimulate the development of granulation tissue. Signup and view all the answers

What type of therapy involves the use of topical and systemic antibiotics?

Pharmacologic therapy Signup and view all the answers

Which dressing is known for maintaining moisture and protecting against bacterial colonization?

Hydrocolloid dressing Signup and view all the answers

What is the primary complication associated with pressure injuries?

Infection Signup and view all the answers

Which type of dressing may be impregnated with antimicrobial substances?

Silver sulfadiazine dressings Signup and view all the answers

What is the main goal for patients at risk for pressure injuries?

Prevention of pressure injuries Signup and view all the answers

Which method of lighting is preferable during a skin assessment for pressure injuries?

Natural or fluorescent lighting Signup and view all the answers

What can prolonged skin contact with body secretions cause?

Excoriation Signup and view all the answers

Which area should NOT be inspected for pressure injuries?

Chest and abdominal area Signup and view all the answers

What indicates an abnormal surface temperature in the skin over pressure areas?

A temperature higher than the surrounding skin Signup and view all the answers

How should a nurse assess the capillary refill in pressure areas?

Gently palpate with fingers or thumb Signup and view all the answers

Which of the following statements regarding temperature assessment is accurate?

Inflammation can cause localized increases in temperature. Signup and view all the answers

Which of the following pressure areas corresponds to a patient lying in a lateral position?

Greater trochanter and ear Signup and view all the answers

What is the primary purpose of assessing the location of a pressure injury in relation to a bony prominence?

To evaluate the severity and risk factors for further injury Signup and view all the answers

How should the size of a pressure injury ulcer be measured?

By measuring length, width, and depth with a standard ruler Signup and view all the answers

What does the assessment of undermining or sinus tracts involve?

Evaluating the wound's dimensions in a clock format Signup and view all the answers

Which of the following components is NOT included in the Braden Scale for Predicting Pressure Sore Risk?

Skin temperature Signup and view all the answers

What category was added to the Norton Scale in 1987?

Medications Signup and view all the answers

A patient scoring below 18 points on the Braden Scale is considered to be at risk for which of the following?

Pressure injury development Signup and view all the answers

When documenting the status of a patient's skin and wounds, what is critical to note?

Changes over time Signup and view all the answers

Which score on the Norton Scale should be regarded as an indicator of risk?

15 or 16 Signup and view all the answers

Which clinical sign is NOT typically associated with infection in a pressure injury?

Decreased appetite Signup and view all the answers

What intervention is recommended for a patient who is immobile or on bed rest?

Repositioned every 2 hours Signup and view all the answers

What must be assessed when inspecting pressure areas for abnormalities?

Skin temperature variations Signup and view all the answers

What method should be used to evaluate the integrity of the skin surrounding a pressure injury?

Both visual inspection and palpation Signup and view all the answers

Which of the following risk factors does the EPUAP, NPIAP, and PPPIA recommend considering for pressure injury assessment?

Device-related pressure Signup and view all the answers

Which of the following is a common abnormal finding during pressure area assessment?

Nonblanching erythema Signup and view all the answers

Which patient demographic may have difficulty regulating body temperature affecting skin condition?

Older patients Signup and view all the answers

In assessing the moisture level, which description would indicate that the skin is constantly moist?

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

What is an effective outcome measure for patients with impaired skin integrity?

Reporting any changes in skin or wound condition Signup and view all the answers

Which of the following descriptions indicates a good response to verbal commands related to sensory perception?

No Impairment Signup and view all the answers

When using the Braden Scale, a patient who walks frequently is categorized in which activity level?

Walks Frequently Signup and view all the answers

What type of tissue consistency might indicate edema during palpation of pressure areas?

Spongy or boggy Signup and view all the answers

How often should a patient typically undergo a pressure injury risk assessment in long-term care settings?

Weekly Signup and view all the answers

What is an indicator of very poor nutritional intake according to the Braden Scale?

Rarely eats more than 1/3 of any food offered Signup and view all the answers

What is the recommended method for measuring the depth of a pressure injury?

Using a sterile applicator swab at the deepest part Signup and view all the answers

What key factor is connected to the incidence of pressure injuries according to research?

Method of assessment Signup and view all the answers

Which issue may contribute to potential compromised dignity in patients with pressure injuries?

Need for assistance with activities of daily living Signup and view all the answers

What should be monitored to assess for potential infection in pressure injuries?

Skin redness and drainage Signup and view all the answers

What is a potential risk associated with patients who slide down in their beds or chairs?

Increased friction and shearing forces Signup and view all the answers

What outcome should be targeted for patients who are mobile concerning their activity levels?

Maintain or improve activity levels Signup and view all the answers

Study Notes

Pressure Injuries

Pressure injuries manifest differently based on severity, reflecting varying tissue resilience.
Muscle is least resistant to pressure, becoming necrotic before skin breakdown.
Pressure distribution from bony prominences is uneven, concentrated at the prominence and decreasing outward.
Superficial skin breakdown might not fully represent the underlying tissue damage.

Staging of Pressure Injuries

Stage 1:
- Non-blanchable erythema (redness that doesn't fade when pressed) on intact skin.
- Often localized over bony prominences.
- May be difficult to identify in darker skin.
Stage 2:
- Partial-thickness loss of dermis, presenting as shallow open wounds or blisters without slough (dead tissue).
Stage 3, 4, and Unstageable:
- Full-thickness tissue loss with exposure of muscle, bone, or supporting structures.
- May involve slough or eschar (dead tissue).
Deep Tissue Pressure Injury:
- Intact skin with localized, non-blanchable maroon, deep red, or purple discoloration.
- May rapidly evolve into blisters or thin eschar.
- May be difficult to detect in darker skin.

Pressure Injury Therapies

Stage 1:
- Cleansing and application of barrier cream and protective dressing.
- Introduction of pressure-redistributing support surfaces and frequent repositioning.
Stage 2:
- Cleansing, moisture-retaining protective dressing, assessment for necrosis and infection, and frequent repositioning.
- Comfort measures are important.
Stages 3, 4, and Unstageable:
- Cleansing, debridement (removal of dead tissue), surgical removal of necrotic tissue if needed.
- Use of medicated moisture-retaining dressings.
- Assessment and treatment of infection.
- Pain management.
Deep Tissue Pressure Injury:
- Cleansing, moisturizers or barrier creams, non-adhesive protective dressing.
- Introduction of pressure-removing support surfaces and elevation of the affected area (if possible).
- Monitor for pressure injury development.

Pressure Injury Progression

Pressure injuries range from discoloration to deep tissue damage with necrosis.
Staging helps classify the degree of tissue damage.

Prevention

Regular patient assessments for pressure injury risk are crucial for prevention.
Consistent and proper repositioning of patients is essential, utilizing techniques that minimize shear.
Patients and family members should be educated on ulcer protection, treatment, and stage assessment.

Diagnostic Tests

Diagnostic tests determine the presence of secondary infection and identify the cause of pressure injury.
White blood cell (WBC) counts indicate inflammation or invasive infection.
Erythrocyte sedimentation rate (ESR) evaluation helps identify osteomyelitis.
Nutritional status assessment with albumin, prealbumin, transferrin, and serum protein levels is important for wound healing.
Urine, stool, or blood cultures may be necessary depending on specific patient situations.
Cultures of deep or infected pressure injury tissue are used to identify the causative organism.

Surgical Debridement

Nonviable tissue removal is crucial for staging and healing wounds.
Surgical debridement may be necessary for deep wounds, subcutaneous tissue involvement, or the presence of eschar.

Autolytic Debridement

Natural breakdown of damaged tissue by the body's own enzymes.
Dressings containing hydrocolloids, alginates, hydrogels, and transparent films maintain moisture for autolytic debridement.
This method is the most selective and causes the least damage to healthy tissue.

Larval Therapy

Larval therapy involves the use of maggots (Phaenicia sericata) for debridement and wound healing.
Maggot secretions break down necrotic tissue, leaving healthy tissue intact.
They also secrete antimicrobial compounds, reduce bacterial growth, and stimulate granulation tissue development.

Skin Grafting

Large wounds may require skin grafting for complete closure.

Pharmacologic Therapy

Topical and systemic antibiotics specific to the infection eradicate any infection present.
Moisture-maintaining dressings (hydrocolloid, transparent film) are used for clean, granulating wounds.
Dressings impregnated with silver sulfadiazine and medical-grade honey offer antimicrobial benefits.
Alginate, foam, and iodine dressings are preferred for deep, exudative wounds.
The type of dressing used changes with wound healing progress.

Nonpharmacologic Therapy

Pressure injuries present various challenges due to risk factors, ulcer types, and impairment levels.
Infection is the most serious complication, requiring adherence to agency protocols and physician orders.
Prompt treatment prevents further tissue damage, pain, and facilitates wound healing.

Pressure Injury Prevention

Pressure injuries are a serious problem, impacting skin integrity, increasing risk for infection and pain, and diminishing quality of life.
Prevention is the primary goal for patients at risk.
Assessment of skin is crucial, ensuring good lighting, comfortable room temperature, and checking for discoloration, abrasions, and excoriations.
Palpation of pressure areas for capillary refill, temperature changes (increased may indicate inflammation), and edema is also important.
When assessing pressure injuries, document location, size, undermining, stage, color, wound bed, and signs of infections.
The Braden Scale is a common tool used to predict pressure injury risk, consisting of six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction & shear) with a total score of 23 points. A score below 18 indicates risk.
The Norton Scale, also used for assessment, evaluates general physical condition, mental state, activity, mobility, incontinence, and medications, with a maximum score of 24, where scores of 15 or 16 indicate risk.
Regular assessments should be conducted upon admission and at subsequent intervals, especially when a change in patient condition occurs.

Pressure Injury Assessment Findings

Normal findings: Skin over pressure areas is intact, capillary refill is brisk, temperature is consistent with surrounding skin, tissues are firm.
Abnormal findings: Non-blanching erythema, abrasions, excoriations, increased temperature, spongy or boggy tissue (edema).
Lifespan considerations: Older adults may have mobility limitations, making them more susceptible to pressure injuries.
Lifespan considerations: Those with spinal cord injuries are prone to pressure injuries over bony prominences.

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Description

Explore the various stages of pressure injuries, their manifestations, and the underlying tissue damage. This quiz delves into the characteristics of different stages, from non-blanchable erythema to full-thickness tissue loss. Assess your understanding of the pathophysiology associated with pressure injuries.