Pressure Injury

Question 1

NPUAP

Answer 1

national pressure ulcer advisor pannel

Question 2

what is a pressure injury

Answer 2

localized damage to skin and underlying soft tissue usually over a bony prominence or related to a medical or other device

Question 3

where are common sites for pressure injury

Answer 3

hips, sacrum, heels, back of head

Question 4

a pressure injury is usually caused in combination with

Answer 4

shear

Question 5

what is the time and pressure for a pressure injury to develop

Answer 5

2hrs 30mmhg

Question 6

what is shear

Answer 6

when you pull a patient up or they fall down and the inner and outer layer separate

Question 7

risk factors for pressure injury

Answer 7

age (related skin changes)
immobility
obesity (no circulation)
thinness (decrease subq)
excessive moisture
poor nutrition/hydration
corticosteroids
previous pressure ulcer
DM

Question 8

slough

Answer 8

necrotic tissue that is moist, stringy, and yellow or gray (devitalized tissue)

Question 9

do you need to debride slough

Answer 9

yes

Question 10

what stages is slough found in

Answer 10

3-4

Question 11

eschar

Answer 11

devitalized dermis that has become leathery or thick and black

Question 12

undermining

Answer 12

area of the ulcer beneath the skin surface that extends under the edge of the wound

Question 13

tunneling

Answer 13

narrow extensions into the surrounding tissue
called sinus tract/fistula

Question 14

stages of pressure injury

Answer 14

1-4, unstageable, deep tissue

Question 15

stage 1

Answer 15

intact skin
non blanchable redness

Question 16

stage 1 in dark pigment skin

Answer 16

may not have visible blanching, color differs form surrounding area

Question 17

what do we need to protect stage 1 from

Answer 17

moisture, pressure, further injury

Question 18

stage 2

Answer 18

partical thickness
red pink wound bed
open blister
skin is broken

Question 19

stage 3

Answer 19

full thickness
subq visible
epibole (rolled edges)
slough and eschar
undermining/tunneling

Question 20

stage 4

Answer 20

full thickness
exposed bone, ligament, tendon, muscle
slough or eschar
undermining and tunneling
epibole

Question 21

if unsure between 1-2 and 3-4 what can you refer to them as

Answer 21

1-2: partial
3-4: full

Question 22

unstageable is when

Answer 22

predominately wound bed is covered with slough or eschar

Question 23

if the unstageable pressure wound is debrided what stage will it be at

Answer 23

3-4

Question 24

deep tissue vs stage 1

Answer 24

deep tissue is purple or marron

Question 25

deep tissue is due to damage of

Answer 25

underlying soft tissue from pressure and/or shear

Question 26

stages should only be used for

Answer 26

pressure injury only

Question 27

at the time of initial assessment of if ulcer deteriorates what stage defines the wound

Answer 27

highest

Question 28

how do we name a healing wound

Answer 28

healing stage (highest stage)

Question 29

do not down

Answer 29

stage

Question 30

pressure injury prediction scale

Answer 30

braden

Question 31

how often should we turn patients

Answer 31

Q2