Pressure Injury

Question 1

Define a pressure injury

Answer 1

A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction

Question 2

Aetiology of pressure injuries

Answer 2

1) intensity - capillary pressure and capillary closing pressure
2) Duration
3) Tissue tolerance

Question 3

What can increase pressure?

Answer 3

1) Impaired mobility
2) Impaired activity
3) Impaired sensory perception

Question 4

Extrinsic factors that contribute to pressure injuries

Answer 4

Moisture
Shear
Friction

Question 5

Intrinsic

Answer 5

Nutrition
Demographics
Oxygen delivery
Skin temperature
Chronic illness

Question 6

Define interface pressure

Answer 6

Interface pressure is the pressure exerted on the skin surface when in contact with a support surface

Question 7

Common sites for a pressure injury

Answer 7

Scapular
Sacrum
Ischium
Occiput
Elbow
Iliac crest
Heel
Ear cartilage
Shoulder
Malleoli

Question 8

Define shear, friction and forces

Answer 8

Shear - moving skin
Friction - heat
Forces - pressure

Question 9

Definition of shearing

Answer 9

Parallel pressure applied to a sliding body against a non-conformable surface causes tissue damage

Question 10

Definition of friction

Answer 10

Friction is rapid or frequent movement against an abrasive surface

Question 11

Define blanching

Answer 11

Skin that whitens under compression due to local occlusion or vasoconstriction of the bloody supply

Question 12

Define reactive hyperaemia

Answer 12

When pressure is removed from a compressed area of tissue the capillaries rapidly refill and dilate overcompensating for deficiencies in oxygen and nutrients, which causes a red flushing of the tissues.

Question 13

Define non-blanching hyperaemia

Answer 13

A reddened area of skin that does not turn white under finger pressure

Question 14

Define a stage 1 pressure area

Answer 14

1) intact skin with non-blanchable redness of a localised area
2) May be painful, firm or soft

Question 15

Define stage 2 pressure injury

Answer 15

1) partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough
2) May also present as an intact or open blister
3) without slough or bruising

Question 16

Define a stage 3 pressure injury

Answer 16

1) full thickness tissue loss
2) subcutaneous fat may be visible
3) Slough may be present but does not obscure the depth of the tissue
4) May include undermining or tunnelling

Question 17

Define a stage 4 pressure area

Answer 17

1) full thickness tissue loss with exposed bone tendon or muscle
2) Slough or Escher may be present on some parts of the wound bed
3) can extend into supporting structures (joint capsule, fascia or tendon)

Question 18

Define an unstageable pressure area

Answer 18

1) full thickness tissue tissue loss in which the base of the ulcer is covered by Slough and/or Escher in the PI bed
2) until enough Slough and/or Eschar is removed to expose the base of the wound, the stage can not be determined

Question 19

Define a suspected deep tissue injury

Answer 19

1) purple or maroon localised area of discoloured intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear
2) tissue can be painful, firm, mushy, boggy or warmer
3) evolution may include a thin blister over a dark wound bed
4) The PI may further evolve and become covered with thin Eschar

Question 20

What are predisposing factors for pressure injuries?

Answer 20

1) chronic illness - diabetes, matastatic carcinoma, renal impairment and lymphoedema
2) conditions that impact on tissue perfusion - smoking, peripheral vascular disease, hypotension, blood dyscrasis
3) impaired sensation and cognition

Question 21

What are the treatment options for pressure injury?

Answer 21

1) manage on a pressure relieving device
2) manage pain
3) regular repositioning
4) high protein diet
5) nutritional supplementation

Question 22

How can shear and friction be reduced?

Answer 22

1) maintain head of bed elevation at 30 degrees
2) appropriate use of transfer aids
3) ensure all contact surfaces, garments and linen are non-abrasive and do nit hinder activity and mobility

Question 23

What are the principles of skin care in relation to pressure injuries?

Answer 23

1) skin assessment daily (within 8 hours of admission)
2) skin hygiene
3) skin moisture maintenance
4) maintenance of stable skin temperature and pH
5) optimise nutritional and fluid intake

Question 24

What is the ideal support surface?

Answer 24

1) comfort and conformity
2) optimal pressure redistribution
3) no bottoming out
4) impermeable and fire retardant
5) water proof
6) non-permeable to bacteria
7) emergency features - CPR deflation