Pressure Injury

Question 1

what is a pressure injury

Answer 1

localized skin and underlying tissue damage
*usually over a bony prominence

Question 2

common PI sites

Answer 2

hips
sacrum
heels
back of head

Question 3

PI usually in combination with

Answer 3

shear
*layers of skin separate

Question 4

time and pressure for PI to occur

Answer 4

2 hours
30 mmhg

Question 5

slough

Answer 5

moist, stringy, and yellow/gray necrotic tissue

Question 6

what dressing should you use for slough

Answer 6

dakin soaked

Question 7

eschar

Answer 7

devitalized dermis that is leathery/thick/black

Question 8

undermining

Answer 8

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

Question 9

tunneling

Answer 9

narrow extensions into surrounding tissue from sides of ulcer
*also called SINUS TRACTS or FISTULA
*ends in another structure of hollow viscous

Question 10

stage 1 PI

Answer 10

skin INTACT
non blanchable redness

Question 11

protection for stage 1 PI

Answer 11

protect from:
moisture
pressure
further injury

Question 12

stage 2 PI

Answer 12

partial thickness loss of skin with exposed dermis
*shallow and open (could be a blister)
*NO slough, eschar, or granulation

Question 13

stage 3 PI

Answer 13

full thickness loss
*SUBQ may be visible
*NO bone, tendon, muscle (3) exposed
*epibole (rolled edges)
*possible slough and eschar
*undermining and tunneling possible

Question 14

stage 4 PI

Answer 14

full thickness and tissue loss
*bone, ligament, tendon, muscle (4) exposed
*epibole, slough, eschar, tunneling, undermining may be present

Question 15

unstageable

Answer 15

full thickness tissue loss and base cannot be seen

Question 16

deep tissue PI

Answer 16

purple/maroon localized area of discolored but INTACT skin or blood filled blister
*from damage to underlying soft tissue from pressure/shear

Question 17

do not

Answer 17

down stage
(document as stage 2 when healing from stage 3)

Question 18

do you debride slough

Answer 18

yes