Pressure Injuries and Skin Care

Question 1

What is the Braden Scale?

Answer 1

It is used to assess pressure injury risk and management plan.
It gives a score from 1 (complete problem) to 4 (no problem) for the following areas:
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and sheer

If the score is less than 18, there is no need for interventions.
15 - 18 is low risk - encourage frequent mobilisation and use a constant low pressure device
13-14 is moderate risk - 2 to 4 hour re-positioning and skin inspection, constant low pressure device
12 or lower is high risk - 2 hour re-positioning and skin inspection, alternating pressure devices

Question 2

What are you assessing for with a skin assessment?

Answer 2

Use sight and feel (palpation) for:

• moisture
• temperature
• general colour
• turgor (lack of elasticity. gently pinch skin - if it doesn’t return to normal quickly it has low turgor - often a sign of dehydration)
• capillary refill (push down on an area of skin. When released, it should return to normal colour within 2 seconds. If it remains white for longer than 2 seconds it is a sign of a circulation issue)

Question 3

What are the causes of pressure injuries?

Answer 3

• shear (dragging, eg across a mattress)
• friction (abrasion of the epithelial surface from rubbing on something)
• pressure (body weight in the same spot for a long period of time)

Question 4

What are risk factors for pressure injuries?

Answer 4

• bony prominence (shoulder blades, heels, sacral area)
• immobility
• inability to lift oneself (eg - can’t raise buttocks off bed when moving position)

Question 5

What are risk factors for pressure injuries?

Answer 5

• bony prominence (shoulder blades, heels, sacral area)
• immobility
• inability to lift oneself (eg - can’t raise buttocks off bed when moving position)
• alteration in mobility or physical activity
• malnutrition and dehydration
• moisture (incontinence)
• alteration to sensation and consciousness (dementia, coma)
• other health conditions such as diabetes, heart disease, circulation disorders, smoking history

Question 6

What are the stages of Pressure Ulcers?

Answer 6

Stage 1 - persistent non-blanching redness. Skin may feel cooler or warmer than the surrounding area, firm, itchy, painful
Stage 2 - partial thickness loss of the dermis. Can present as a wound that is shallow with a red or pink wound bed. Or may be an intact fluid-filled, or open blister. Sometimes shiny or dry, without any bruising present
Stage 3 - Full thickness skin loss. Subcutaneous fat may be visible. Thick yellow tissue (slough) may be present. There may be undermining of the wound.
Stage 4 - full thickness tissue loss with exposed bone. Thick yellow tissue or black necrotic tissue may be present. Often has undermining. Can cause osteomyelitis (bone infection)