9.4 Assessment/Management of Pressure Injuries

Question 1

Pressure Injuries

Answer 1

• They are sentinel events

Question 2

Classifications

Answer 2

Stage 1
- Intact skin with non-blanchable redness

Stage 2
- Partial thickness of epidermis and dermis

Stage 3
- Full thickness (epidermis and dermis) with visible fat

Stage 4
- Full thickness with exposed bone, muscles, and tendons

Deep Tissue Pressure Injury
- Persistent non-blanchable deep red discoloration
- Blood filled blister, depth unknown

Unstageable
- Obscured full thickness tissue loss
- Base of wound cannot be visualized
- Can be yellow/tan/gray/green/brown

Question 3

Medical Device Related Pressure Injury

Answer 3

• Results from medical devices

Question 4

Mucosal Membrane Pressure Injury

Answer 4

• Mucosal membrane injury
• Usually unstageable

Question 5

Definitions

Answer 5

Tissue Ischemia
- Obstructed blood flow to tissue causing death

Reactive Hyperemia
- Dilation of superficial capillaries causing skin redness

Blanchable Hyperemia
- Redness that turns lighter when palpated

Nonblanchable Hyperemia
- Redness that persists even when palpated (indicating tissue damage)

Question 6

Unstageable Ulcers

Answer 6

• You must describe the injury
• What do you see
• How would you stage this ulcer
• Is the wound healing
• If eschar obscures tissue loss then this is unstageable.

Question 7

Stage 1

Answer 7

• Blanchable erythema
• Changes in sensation, temperature, firmness
• PURPLE/MAROON INDICATE DEEPER TISSUE INJURY

Question 8

Stage 2

Answer 8

• Partial thickness with exposed dermis
• May present as intact or ruptured blister

Question 9

Stage 3

Answer 9

• Full thickness
• Fat is visible and epibole (rolled wound edges)
• Slough and eschar visible

Question 10

Stage 4

Answer 10

• Full thickness and tissue loss
• Exposed fascia, muscle, tendon, ligaments, cartilage, or bone.

Question 11

Healing Process

Answer 11

• Inflammation Phase
• Proliferation Phase
• Maturation Phase (remodeling phase)

Question 12

Inflammation Phase

Answer 12

• Hemostasis Established
• Neutrophils go to wound to remove bacteria
• Cytokines promote cell proliferation and synthesis of extracellular matrix molecules

Question 13

Proliferation Phase

Answer 13

• New tissue is formed and wound contracts

Angiogenesis
- New capillaries are formed

Granulation
- Fibroblasts produce collagen (highly vascular due to angiogenesis and appears red and beefy)

Epithelialization
- Epithelial cells migrate to wound edges and makes new skin (which appears pink and pale). Edges are usually thin and pearly

Wound Contraction
- Reduction in wound depth and size

Question 14

Maturation/Remodeling

Answer 14

• Scar tissue is remodeled and strengthened (shrinking and thinning of scar and becomes more skin like in color) - Darker skin may look like hypopigmentation
• Lasts for a year or longer
• Scar tissue is weaker than normal tissue

Question 15

Braden Scale

Answer 15

• RISK ASSESSMENT SCALE

1. Sensory Perception (can patient respond to pressure-related discomfort)
2. Moisture (Patients degree of exposure to incontinence, sweat, drainage)
3. Activity (how active are they)
4. Mobility (are they able to change positions on their own)
5. Nutrition
6. Friction/shear (how much of a risk are they for this)

> 19 - low risk
15-18 - mild risk
13-14 - moderate risk
10-12 - high risk
<9 - very high risk

Question 16

Assessment

Answer 16

• Upon admission every patient should have an entire body assessment for existing issues
• Identified issues should document size, color, drainage, odor, and general appearance.

Question 17

Nursing Interventions

Answer 17

• Topical skin care and incontinence management
  (Protect bony prominences, skin barriers for incontinence)
• Turn patient every 1-2 hours
• Decrease pressure on bony prominences

Question 18

Acute Care

Answer 18

• Debridement
• Nutrition
• Education
• Protein

Question 19

Complications of Wound Healing

Answer 19

• Hemorrhage
• Infection
• Dehiscence
• Evisceration
• Fistula

Question 20

Dressing Change

Answer 20

• Evaluate pain
• Describe procedure steps
• Gather supplies
• Recognize normal signs of healing

Question 21

Types of Dressings

Answer 21

Gauze
- Most common (causes little wound irritation) Best used for wounds with moderate drainage, deep wounds, and tunnels.

Transparent Film
- Traps moisture over the wound. Used for wounds with minimal tissue loss

Hydrocolloid
- Maintains moist environment. Made of gel and have adhesives

Hydrogel
- Maintains moist environment. Used for wounds with significant drainage. Secondary dressing usually applied over hydrogel.

Question 22

VAC Therapy

Answer 22

• Vacuum assisted closure therapy. Negative pressure to drain wound fluids and stimulate granulation and reduces bacteria.