Wound Care and Pressure Injuries Quiz

Pressure injuries form over bony prominences in immobile patients.
Common bony prominences include the back of the head, shoulders, elbows, lower back, hips, inner knees, and heels.
Pressure injuries are a localized skin and/or underlying tissue damage due to pressure.
Pressure injuries cause tissue necrosis.
Pressure injury risk factors include length of time pressure is exerted, ability of tissue to tolerate pressure, age, density, collagen, and comorbidities.
Shearing force is pressure exerted on the skin when it adheres to the bed linen.
Friction is two surfaces rubbing against each other, like bed sheets and skin.
Moisture factors include excessive diaphoresis, urine, and stool.
Pressure injuries are graded and staged according to the depth of tissue damage, from Stage 1 (minor) to Stage 4 (severe).
Slough is stringy, yellow dead tissue.
Eschar is black/brown necrotic tissue.
Blisters on the heels can be a result of pressure injury.

Differentiate among healing by primary, secondary, and tertiary intention.
Describe wound healing principles.
Explain the nursing process in caring for individuals experiencing a wound.
Describe factors that delay healing or result in complications.
Explain the etiology and clinical manifestations of pressure injury.
Discuss using the Braden Scale to assess for pressure injury risk.
Identify measures used to prevent pressure injury development.
Explain the nursing and collaborative management of pressure injury with or without infections of the integument.

Pressure ulcers are graded and staged based on the deepest area of tissue damage (Stage 1 to Stage 4)
Staging may require removing slough and/or eschar.

Signs/symptoms include leukocytosis (WBC > 10,000), fever, increased ulcer size, odor, or drainage, necrotic tissue, and pain.
Untreated ulcers can lead to cellulitis, chronic infection, sepsis, and possibly death.

Wound care/Prevent infection: Wound care, proper nutrition, pain relief, pressure relief
Control co-morbidities: Treating comorbidities, such as Hypertension, reduces risks to injury.
Infection management includes getting cultures to determine the organism and the most effective antibiotic.
Cultures must be taken before any antibiotic is given.
Psychological implications include concerns about scars, drainage, or odor.

Increase caloric and protein intake using wound healing diets, dietary supplements, enteral or parenteral feedings.
Monitor weight daily.

Document and describe size, stage, location, exudate, infection, pain, and tissue appearance.
Keep ulcer bed moist
Cleanse with nontoxic solutions
Surgical debridement (removal of necrotic tissue).
Dressings Maintain moisture

Aim to convert the environment (molecular and cellular) of a chronic wound to that of an acute wound.

Primary intention: clean, closed wounds (e.g., surgical incision).
Secondary intention: wounds with significant tissue loss, large wounds that heal from the bottom up (e.g., pressure ulcers).
Tertiary intention: wounds that are initially left open to allow for infection resolution, then closed.

Dehiscence
Post-op infection
Hypertrophic scar
Keloid scar.
Wound measurement methods: centimeters, oriented from head to toe, side to side, and depth if appropriate.

Assess pressure injury risk within 1 hour of admission and at periodic intervals.
Document any pressure injuries present on admission.
Patients without any injuries are reassessed every 12-24 hours, Patients requiring turning and positioning should be assessed every 2 hours, Assess skin temperature using your hands. If skin feels warm initially, then cooler.

Look for areas of skin darker than surrounding skin.
May appear with red, blue, or purple hues in darker skin tones
Use natural light for accurate assessment; fluorescent light can skew results.
Touch the skin to feel consistency; boggy or edematous tissue may indicate a pressure injury.
Ask about pain or an itchy sensation.