Pressure Injurys

Question 1

What is a pressure injury?

Answer 1

A localised damage to the skin and underlying soft tissue thats usually, but not always, over a body prominence

Question 2

What type of devices can pressure injurys be caused by?

Answer 2

External medical devices, these wounds are then referred to as medical device-related pressure injurys (MDRPIs)

Question 3

Can mucous membranes (such as the nose, mouth, lungs, and stomach) sustain pressure injurys?

Answer 3

Yes. Although the anatomy of mucous membrane sites isn’t consistent with pressure injury staging guidelines. For this reason, pressure injuries to mucous membranes can’t be staged using the pressure injury staging system.

Question 4

What are two examples of where mucous membranes can (such as the nose, mouth, lungs, and stomach) sustain pressure injurys?

Answer 4

1. From endotracheal tubes
2. From nasogastric tube stabilisers

Question 5

When does shear occur?

Answer 5

When layers of tissue move in opposite, parallel directions, resulting in stretching, occluding or the tearing of blood vessels and disruption of blood flow to the affected area.

Question 6

Disrupted blood flow can lead to what?

Answer 6

Tissue ischemia and tissue death

Question 7

How long can it take to notice a shear injury?

Answer 7

It can take several days for the tissue damage to ‘surface’ and show itself, typically by changes in colour, temperature, and texture

Question 8

Pressure injurys are staged using what system?

Answer 8

The NPUAP staging system

Question 9

Do we backstage pressure injurys? I.e saying that an S3PI is healing to an S2PI?

Answer 9

No, once a pressure injury is characterised i.e “S3PI”, it is always that, it can either be a healing S3PI or a non-healing S3PI. If a wound is worsening it can be restaged.

Question 10

What does HAPIs stand for?

Answer 10

Hospital-acquired pressure injuries

Question 11

What are the disadvantaged for a patient with a HAPIs?

Answer 11

Higher mortality rate, longer length of stay, and a higher chance of readmission + increased cost of care.

Question 12

Determining the stage of a pressure injury comes down to what factors?

Answer 12

Presence of fluid in the wound
Colour of the area
Type of tissue exposed or directly palpable.

Question 13

What are some things we can do as nurses to prevent a HAPI?

Answer 13

Turning and repositioning the patient frequently
Padding bony prominences (pillow between knees ect)
Keeping the elevation of the head at 30 degrees
Ensuring the surface the patient is on allows them to move side to side
Floating the heels off the mattress
Promoting PH-balances skin cleansers followed by moisturisers and protectants
Containing fecal and urinary incontinence to the best we can (pads)
Optimising patients nutritional status
Provide a pressure redistribution mattress and chair pad for those at high risk
Assess for tissue breakdown
Collaborate with the MDT to optimize care interventions.

Question 14

What is the acronym to use when preventing pressure injuries and what does it stand for?

Answer 14

S - Surfaces and Devices
S - Skin inspection
K- Keep moving
I - Incontinence and moisture
N - Nutrition and hydration

Question 15

Where on the body are pressure injuries most likely to occur?

Answer 15

Can happen anywhere but Heels, sacrum and ankles are more common

Question 16

Describe key points to the acronym SSkin inspection to prevent pressure injuries

Answer 16

Carried out regularly (identify any discolouration, change in temperature, swelling and any pain or discomfort)
Pressure mapping can be used to identify the intensity of pressure
Too much bedding can cause pressure and make sure the chair they are using is the chair (sit with knees at a 90 degree angle)
Watch where the feet of tall people are, as the feet might be touching the end and cause pressure

Question 17

What is the knee break technique?

Answer 17

When moving a client in bed, bring their knees up so there feet are braced on the bed before lifting the head of the bed, so their heels don’t slide along the sheets and cause friction and also help reduce pressure on the sacrum and heels.

Question 18

Describe key points to the acronym Keep moving to prevent pressure injuries

Answer 18

Having a mobility plan in place helps ensure care is received to meet a person’s needs
The plan should include a repositioning schedule, or walking schedule, aides and people required
Shower and toilet chairs can lead to pressure damage

Question 19

Describe key points to the acronym Incontinence and moisture to prevent pressure injuries

Answer 19

Incontinence products such as pads, ensure they are changed if full prior to position change as they increase the risk of pressure and skin damage
Someone who experiences incontinence is 40% more likely to sustain a pressure injury
Ensure incontinence products are the right size and shape for the person

Question 20

Describe key points to the acronym Nutrition and hydration to prevent pressure injuries

Answer 20

Nutrition plays a major part in maintaining optimum skin health. Malnutrition screening and observing what, and the quantity of food and drink taken, and a regular weight check is vital for pressure injury prevention
Overweight people are also at risk. Research suggests in the over 65 age group, as many as 40% are malnourished

Question 21

How many stages of pressure injuries are there?

Answer 21

4 stages

Stage 1
Stage 2
Stage 3
Stage 4

Question 22

Characteristics of a stage 1 pressure injury?

Answer 22

Skin is intact with an area of nonblanchable erythema, Meaning when you press on the reddened area, it doesn’t turn white or become pale
Stage one doesn’t describe the layer of tissue that has been impacted, only that localised skin is intact, red and doesn’t blanch

Question 23

Characteristics of a Stage 2 pressure injury

Answer 23

Partial skin loss with exposed dermis
A wound that is pink or red in colour, consisting of moist, viable tissue
Alternatively, stage 2 pressure injuries can present as an intact or ruptured fluid-filled blister

Question 24

What stages do nurses confuse with deep tissue pressure injuries?

Answer 24

Stages 1 and 2

Question 25

How can deep tissue injuries present?

Answer 25

Deep tissue pressure injuries can present as a blood-filled blister or they may have epidermal separation and a darkened wound bed. A deep tissue pressure injury can progress to an unstable wound. When this happens, the wound is recategorised as an unstageable pressure injury

Question 26

What are deep tissue pressure injuries?

Answer 26

Localised areas that:

Have intact or non-intact skin
Don’t blanch
Are deep red, purple or maroon in colour