WK 7: Pressure Injury

Question 1

What is a Pressure Injury?

Answer 1

Localized injury to skin and/or underlying soft tissue as a result of excessive or prolonged pressure, shear, and tissue deformation

Question 2

What are causes pressure injuries?

Answer 2

o Pressure
o Shearing force
o Friction
Excessive moisture

Question 3

What are risk factors for pressure injuries

Answer 3

o Impaired mobility
o Impaired activity
o Impaired sensory perception
o Malnutrition or obesity
o Compromised skin integrity
o Increasing age
o Compromised or reduced blood supply to pressure points
Severely compromised status of health.

Question 4

Pressure ulcer staging

Answer 4

o Stage 1: just erythema of the skin.
o Stage 2: erythema with the loss of partial thickness of the skin including epidermis and part of the superficial dermis.
o Stage 3: full thickness ulcer that might involve the subcutaneous fat.
o Stage 4: full thickness ulcer with the involvement of the muscle or bone

Question 5

Nursing assessment of pressure ulcers

Answer 5

Braden Scale: The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status.

Question 6

Nursing management for the prevention of pressure ulcers

Answer 6

1. Cleaning and debriding the wound to remove debris and dead tissue from the wound bed,
   
   2. Controlling inflammation and treating infection to prepare the wound for healing, and
      Providing moisture balance for healable wounds, and moisture reduction for nonhealable and maintenance wounds

Question 7

What disciplines are involved in the management of pressure injuries

Answer 7

· dietician
wound care specialist