HN: pressure injuries

Question 1

risk factors for pressure injuries

Answer 1

• immobility/inactivity
• friction/shear
• nutrition
• moisture
• old age
• low sensory perception (inability to feel pressure injuries)
• disease conditions

Question 2

areas at risk of pressure injury

Answer 2

• head
• elbow
• knee (inner/outer)
• sacral (tailbone area)
• heel
• toes
• shoulder blades
• back
• hip

back and hip more common

Question 3

causes of pressure injuries

Answer 3

• tolerance of skin and supporting structures (influenced by intrinsic + extrinsic factors)
• intensity and duration of pressure

Question 4

characteristics of stage 1 pressure injury

Answer 4

• skin layer intact with redness
• fat and muscle layer intact
• bone layer unexposed

Question 5

characteristics of stage 2 pressure injury

Answer 5

• skin layer partial thickness loss involving epidermis (top layer of skin)
• fat and muscle layer intact
• bone layer unexposed

Question 6

characteristics of stage 3 pressure injury

Answer 6

• skin layer full thickness loss
• fat layer damaged with possible necrosis
• muscle layer intact
• bone layer unexposed

Question 7

characteristics of stage 4 pressure injury

Answer 7

• skin layer full thickness loss
• fat layer damaged/necrosis occurs
• muscle layer damaged with possible necrosis
• bone layer exposed

Question 8

characteristics of deep tissue injury

Answer 8

• skin layer intact with localised maroon/purple discolouration
• fat, muscle and bone layer not immediately identifiable

Question 9

characteristics of unstageable pressure injury

Answer 9

• skin layer full thickness loss
• fat, muscle and bone layer not immediately identifiable until slough is removed

Question 10

when to assess for pressure injuries?

Answer 10

constantly, as much as possible

e.g.
* after showering of patient
* during diaper changing for patient
* when doing turning of patient
* whenever patient complains of discomfort at pressure points