Module 4 - Pressure injuries. Prediction, prevention & management.

Question 1

Define pressure injury.

Answer 1

A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Question 2

Describe the aetiology of pressure ulcers.

Answer 2

1. Intensity
• capillary pressure
• capillary closing pressure
2. Duration
3. Tissue tolerance

Question 3

What increases the risk of pressure injury?

Answer 3

-Impaired Mobility, Impaired Activity, Impaired Sensory Perception causes increased pressure.
- Extrinsic and intrinsic factors affect tissue tolerance.
+ Extrinsic factors - moisture, shear, friction
+ Intrinsic factors - Nutrition, Demographics, Oxygen Delivery, Skin Temperature, Chronic Illness

Question 4

Define pressure.

Answer 4

Pressure is defined as a perpendicular force.

Question 5

Define interface pressure.

Answer 5

Interface pressure is the pressure exerted on the skin surface when in contact with a support surface.

Question 6

Define shearing.

Answer 6

Parallel pressure applied to a sliding body against a non-conformable surface causes tissue damage.

Question 7

Define friction.

Answer 7

Friction is rapid or frequent movement against an abrasive surface.

Question 8

Define blanching.

Answer 8

Skin whitens under compression due to local occlusion or vasoconstriction of the blood supply.

Question 9

Define blanching hyperaemia (erythema).

Answer 9

An area of erythema that turns white under finger pressure. A warning sign that the skin is at risk. If ignored reperfusion injury will lead to irreparable tissue damage. Blanching hyperaemia is difficult to detect in dark or tanned skin.

Question 10

What is reactive hyperaemia?

Answer 10

When pressure is removed from a compressed area of tissue the capillaries rapidly refill and dilate overcompensating for deficiencies in O2 and nutrients, which causes a red flushing of the tissues. This is a normal response and will subside within 5 to
20 minutes.

Question 11

What is non-blanching hyperaemia?

Answer 11

A reddened area of skin that DOES NOT TURN WHITE under finger pressure. This indicates that the microvasculature system within the tissues has been compromised due to unrelieved pressure. Inflammatory changes are now present within the tissues. If non-blanching hyperaemia is present in the tissues after 30 minutes a Stage 1 pressure ulcer is present

Question 12

Describe a Stage 1 pressure injury.

Answer 12

• Intact skin with non-blanchable redness of a localized area usually over a bony prominence. 
• Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. 
• The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
• May be difficult to detect in individuals with dark skin tones. 
• May indicate “at risk” persons (a heralding sign of risk)

Question 13

Describe a Stage 2 pressure injury.

Answer 13

• Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. 
• May also present as an intact or open/ruptured serum-filled blister.
• Presents as a shiny or dry shallow ulcer without slough or bruising.
• Stage 2 should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Question 14

Describe a Stage 3 pressure injury.

Answer 14

• Full thickness tissue loss. 
• Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. 
• Slough may be present but does not obscure the depth of tissue loss. 
• May include undermining and tunnelling.
• The depth of a Stage 3 pressure ulcer varies by anatomical location. 
• The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage 3 ulcers can be shallow. 
• In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers. 
• Bone/tendon is not visible or directly palpable.

Question 15

Describe a Stage 4 pressure injury.

Answer 15

• Full thickness tissue loss with exposed bone, tendon or muscle. 
• Slough or eschar may be present on some parts of the wound bed. 
• The depth of a Stage 4 pressure injury varies by anatomical location. 
• The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. 
• Stage 4 injuries can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. 
• Exposed bone/tendon is visible or directly palpable

Question 16

Describe an unstageable pressure injury.

Answer 16

• Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the PI bed.
• Until enough slough and/or eschar is removed to expose the base of the wound, the stage cannot be determined. 
• Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Question 17

Describe a suspected deep tissue injury.

Answer 17

• Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 
• Deep tissue injury may be difficult to detect in individuals with dark skin tones.
• Evolution may include a thin blister over a dark wound bed. 
• The PI may further evolve and become covered by thin eschar. 
• Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Question 18

What risk prediction scales are used for identifying risk of pressure injury?

Answer 18

• Braden Scale
• Waterlow Score
• Norton Score
• Gosnell Scale

Question 19

What are other predisposing factors for pressure injuries?

Answer 19

• Chronic illness such as diabetes, metastatic carcinoma, renal impairment and lymphoedema
• Conditions that impact on tissue perfusion (smoking, peripheral vascular disease, hypotension, blood dyscrasia)
• Impaired sensation and cognition

Question 20

Describe pressure injury assessment and monitoring.

Answer 20

• Measurement of the wound size and depth,
• Amount and type of exudate,
• Appearance of the wound bed,
• Condition of the wound edges,
• Signs of clinical infection,
• Appearance of peri-wound skin,
• Undermining, sinus tracts and tunnelling,
• Wound odour, and
• Level of pain and discomfort
• Consider microbiology and histopathology

Question 21

Describe pressure injury wound management.

Answer 21

• Cleanse the peri-wound skin and PI when wound dressings are changed
• Debride as indicated
• Select wound dressings based on:
  comprehensive ongoing clinical assessment
  management of pain, odour, exudate and infection, wound size and location, cost and availability, patient preference
• Patients with stage III or IV pressure injuries that are non-responsive to
  contemporary topical treatments should be evaluated for surgical intervention

Question 22

Describe treatment of pressure injuries.

Answer 22

• Manage patients on a high specification support surface
• Manage pain
• Reposition patients to reduce duration and magnitude of pressure
• Provide high protein oral nutritional supplements in addition to a regular
  diet for patients with a pressure injury
• Consider multivitamin supplements in patients with a pressure injury who are identified as having nutritional deficits
• Consider arginine supplements in patients with a stage II or greater pressure injuries

Question 23

What education should be given to patients with pressure injuries?

Answer 23

- relieve pressure regularly on all body
parts
- avoid activities that cause shear and
friction
- ensure adequate fluid intake and a
nutritionally balanced diet
- inspect the skin daily for signs of
redness or damage

Question 24

Skin care.

Answer 24

• Skin should be kept clean and free from all potentially irritating or macerating substances
• Avoid alkaline soaps and detergents which alter the acid mantle (pH4-6.8) of the skin
• Maintain skin hydration by ensuring adequate fluid intake and the daily use of topical moisturiser
• Eliminate/reduce contact with plastic support surfaces or sheets

Question 25

REACTIVE: STATIC(NON-POWERED) EQUIPMENT

Answer 25

• Conformable materials to increase the load bearing surface
• High density, low resistance (LR or memory foam) overlays or cushions
• Foam overlays with 2-way stretch cover
• Polyester fibre overlay or cushion with2-way stretch cover
• Air or gel filled overlays or cushions

Question 26

REACTIVE: LOW AIR LOSS MATTRESSES

Answer 26

• Distributes pressure –conforms to body

* Constant air from surface of mattress to keep skin dry

Question 27

ACTIVE: ALTERNATING MATTRESSES

Answer 27

• Alternates pressure off-loading every 10–15 minutes
• Minimise layers between patient and mattress
• Heels need additional attention

Question 28

What are IDEAL SUPPORT SURFACE

FEATURES?

Answer 28

• Comfort and conformity
• Optimal pressure redistribution
• No “bottoming out”
• Impermeable and fire retardant covers
• Water proof
• Non-permeable to bacteria
• Emergency features – CPR deflation

Question 29

What is the National Safety and Quality Health Service Standards - Standard 8?

Answer 29

**Preventing and Managing Pressure Injuries
- Clinical leaders and senior managers of a health service organisation implement evidence-based systems to prevent pressure injuries and manage them when they do occur.
- Clinicians and other members of the workforce use the pressure injury
preventing and management systems.