Pressure injuries

Question 1

pathophysiology of pressure wounds

Answer 1

pressure leads to increased intracapillary blood pressure which decreases blood flow to the soft tissue and obstructed lymphatic channels

local tissue ischemia

Increase and metabolic waste and acidosis leads to an increase in cell death
Capillary permeability and local edema increases further limiting circulation and tissue necrosis

Decrease fibrinolysis leading to fiber deposits leading to micro thrombi, thus further occluding vessels and an increase in necrosis

Question 2

Extrinsic factors of pressure injury, creation

Answer 2

amount of pressure
Duration of pressure
Friction
Shear
Moisture
Temperature

Question 3

Intrinsic factors for pressure injuries

Answer 3

muscle atrophy, impaired mobility
Medication’s
Malnutrition
Medical conditions, impaired sensation, previous pressure injury
Advanced age

Question 4

stage 1 pressure injury

Answer 4

non blanchable erythema

localized
Typically over bony prominences
Difficult to detect with dark pigmented skin

Question 5

stage 2 pressure injury

Answer 5

partial thickness, skin loss with exposed dermis

Red or pink wound without slough or granulation tissue

Usually moist

Not skin, tears, dermatitis, or maceration

Question 6

stage three pressure injury

Answer 6

Full thickness, skin loss

Adipose is visible

Slough and eschar may be present

mining tracks tunneling and epibole possible

Question 7

stage 4 pressure injury

Answer 7

Full thickness, skin and tissue loss

exposed fascia, muscle tendon ligament cartilage or bone

May have slough or eschar

epibole undermining tracks and tunneling are common

Question 8

unstagable pressure injury

Answer 8

Obscured full thickness, skin and tissue loss

Base covered by slough or eschar

True depth can’t be determined

Question 9

Deep tissue pressure injury

Answer 9

Non-blanchable, deep, red, maroon or purple discoloration

Localized area of discolored intact or non-intact skin

May present as a dark wound bed or blood filled blister

Damage of underlying soft tissue at the bone muscle interface

Difficult to detect in dark skin tones

Question 10

Mucosal membrane pressure injury

Answer 10

found on mucous membranes

Typically associated with use of a medical device

Cannot be staged