Pressure injury management

Question 1

Define pressure injury

Answer 1

Localised injury to the skin or underlying tissue over a bony prominence as a result of pressure… can also be combined with friction and shearing forces

Question 2

define the following levels of skin breakdown:

1. Hyperaemia
2. Ischaemia
3. Necrosis
4. Ulceration

Answer 2

1. redness and is alleviated after 1 hr after intervention
2. Occurs after 2-6hrs; may take 36hrs to be alleviated
   3.

Question 3

How do you prevent pressure injuries?

Answer 3

1. risk factors and assessments
2. skin and tissue assessment
3. preventative interventions
   4.

Question 4

what are the pressure factors associated with risk of PI

Answer 4

• impaired mobility
• impaired activity
• impaired sensory perception

Question 5

explain the Stage 1 PI

Answer 5

Non-blanching erythema

Question 6

Stage 2 PI

Answer 6

partial thickness, blister that’s not broken, or broken skin subcutaneous

Question 7

stage 3 PI

Answer 7

full thickness, injury goes under subcutaneous tissue

Question 8

stage 4 PI

Answer 8

full thickness: muscle tendon and bone evident with or w/o forceps

Question 9

what’s an unstageable PI?

Answer 9

full thickness skin or tissue with unknown depth

Question 10

what nursing interventions to prevent PIs?

Answer 10

Surface
Skin Inspection and/or protection
Keep moving
Incontinence 
Nutrition