Pressure Injuries

Question 1

Most at risk pt’s for pressure injuries

Answer 1

SCI
Hospitalized pts
Long term care

Question 2

Pathophys of pressure

Answer 2

Decreased bf to soft tissue, obstructed lymphatic channels

• Local tissue ischemia
• Inc Metabolic waste and acidosis = cell death
• inc capillary permeability and local edema, circulation and tissue necrosis
• dec fibronlysis = more deposits to microthrombi

Question 3

Prone locations of PI

Answer 3

Ant tib, ant knee, iliac crest

Question 4

Sidelying locations of PI

Answer 4

Malleolus, Medial/lateral femoral condyles, greater troch, lateral femoral epicondyle, ear

Question 5

Seated locations of PI

Answer 5

Sacrum/coccyx , Ischial tub, greater troch

Question 6

Stage I

Answer 6

Non-blancable erythema

• localized
• typically over bony prominence
• Difficult to detect w/ dark skin

Question 7

Stage II

Answer 7

Partial thickness skin loss with exposed dermis, red or pink wound W/O slough or granulation tissue

• Usually moist
• NOT SKIN TEARS, DERMATIS, MACERATION

Question 8

Stage III

Answer 8

Full thickness skin loss

• adipose visible
• Slough present maybe
• Undermining, tracts, epibole

Question 9

Stage IV

Answer 9

Full thickness skin loss and tissue loss
- Bone exposed, tendon, or muscle
- Maybe have slough and eschar,
undermining and tracts common

Question 10

Unstageable

Answer 10

Obscured full thickness skin and tissue

- Eschar/slough covered, true depth cant be determined

Question 11

Prevention

Answer 11

Avoid side positioning- 30º lateral instead!

Question 12

Bates Jensen Would assessment tool

Answer 12

• 15 item

- Wound severity

Question 13

Pressure Ulcer Scale for Healing (PUSH)

Answer 13

• Monitor healing of ulcers

Question 14

Cleanse PI

Answer 14

• normal saline
• Tap
• Antiseptics (for confirmed/suspected infection, high level of debris or bacteria, SHORT TERM only)
• Do not debride eschar