Pressure Injuries

Question 1

Stage one pressure injury

Answer 1

A Stage 1 pressure injury is the earliest stage of a pressure ulcer, characterized by:

• Intact Skin: The skin remains unbroken.
• Non-blanchable Redness: A localized area of persistent redness that does not fade (blanch) when pressure is applied. On darker skin tones, the discoloration might appear differently, such as purple or blue.
• Other Symptoms: The affected area may feel warmer or cooler than the surrounding skin and might be painful, firm, soft, or slightly swollen.

• Relieving Pressure: Frequent repositioning to alleviate pressure on the affected area.
• Protective Measures: Use of cushioning or padding to reduce pressure.
• Moisturization and Skin Care: Keeping the skin clean and moisturized to avoid further damage.
• Observation: Monitoring for any changes or progression to more advanced stages of pressure injury.

Early intervention at this stage can prevent the injury from worsening.

Question 2

Stage 2 pressure injry

Answer 2

A Stage 2 pressure injury involves partial-thickness skin loss and is more advanced than Stage 1.

• Partial-thickness Skin Loss: The outermost layer of the skin (epidermis) and possibly part of the dermis are damaged or lost.
• Shallow Open Sore: The injury appears as a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.
• No Slough: There is no dead tissue (slough) present at this stage.
• Pain: The area may be painful, and the surrounding skin may feel warm or tender.

• Pressure Relief: Continued repositioning and the use of specialized mattresses or cushions to reduce pressure on the affected area.
• Wound Care: Gentle cleaning of the wound and the application of appropriate dressings to promote healing and protect the area.
• Moisture Management: Keeping the area clean and dry to prevent infection and further skin breakdown.
• Monitoring: Regular assessment to ensure that the wound is healing and not progressing to a more severe stage.

Early treatment of a Stage 2 pressure injury can prevent

Question 3

Stage 3 pressure injury

Answer 3

A Stage 3 pressure injury (also known as a pressure ulcer or bed sore) is characterized by full-thickness loss of skin. This means the damage has extended through the epidermis and dermis into the subcutaneous tissue, but it does not yet expose bone, tendon, or muscle.

Key features of a Stage 3 pressure injury include:
- Full-thickness skin loss: The wound goes deep into the skin layers but does not reach deeper tissues like muscle or bone.
- Necrosis: Dead tissue may be present, often appearing as yellowish, slough-like material.
- Visible fat: Fat tissue may be visible in the wound bed.
- Undermining and tunneling: These can occur when the wound extends beneath the surrounding intact skin.

Treatment typically involves wound care to keep the area clean, moist, and free from infection, relieving pressure on the affected area, and addressing underlying health issues (such as mobility or circulation problems) that may have contributed to the injury.

Question 4

Stage 4 pressure injury

Answer 4

A Stage 4 pressure injury is the most severe form of pressure ulcer, involving full-thickness tissue loss with extensive damage. It extends through the skin, subcutaneous tissue, and down to deeper structures like muscle, bone, tendons, or joints.

Key features of a Stage 4 pressure injury include:
- Full-thickness tissue loss: This means the injury extends beyond the skin into muscle, bone, or supporting structures.
- Exposed structures: Bone, tendon, or muscle may be visible or directly palpable.
- Slough and eschar: Dead tissue may cover parts of the wound bed and appear yellow, tan, gray, or black.
- Undermining and tunneling: There may be significant undermining or tunneling, where the wound extends under the surrounding intact skin.

Treatment for a Stage 4 pressure injury is complex and may include:
- Debridement: Removal of dead or infected tissue to promote healing.
- Infection control: Careful management to prevent or treat infections.
- Pressure relief: Relieving pressure on the affected area using special mattresses or cushions.
- Surgical intervention: In some cases, surgery may be required to close the wound, especially if the injury is extensive.

Question 5

Stage 4 pressure injury

Answer 5

A Stage 4 pressure injury is the most severe form of pressure ulcer, involving full-thickness tissue loss with extensive damage. It extends through the skin, subcutaneous tissue, and down to deeper structures like muscle, bone, tendons, or joints.

Key features of a Stage 4 pressure injury include:
- Full-thickness tissue loss: This means the injury extends beyond the skin into muscle, bone, or supporting structures.
- Exposed structures: Bone, tendon, or muscle may be visible or directly palpable.
- Slough and eschar: Dead tissue may cover parts of the wound bed and appear yellow, tan, gray, or black.
- Undermining and tunneling: There may be significant undermining or tunneling, where the wound extends under the surrounding intact skin.

Treatment for a Stage 4 pressure injury is complex and may include:
- Debridement: Removal of dead or infected tissue to promote healing.
- Infection control: Careful management to prevent or treat infections.
- Pressure relief: Relieving pressure on the affected area using special mattresses or cushions.
- Surgical intervention: In some cases, surgery may be required to close the wound, especially if the injury is extensive.