Pressure Injuries

Question 1

define a pressure injury

Answer 1

local damage to skin and underlying tissue (usually over a bony prominence or related to a medical or other device). Skin can be intact or open and may be painful

Question 2

under what conditions will CMS decline hospital reimbursement for pressure injury care

Answer 2

if the injury was not present on admission (within 48 hours of admission) and has progressed to stage 3 or 4.

Question 3

what are the four factors that influence the etiology of pressure wounds

Answer 3

pressure, friction, shear, and moisture

Question 4

define pressure

Answer 4

force is applied perpendicular to bony prominence or device

Question 5

where does pressure exert the most damage

Answer 5

in areas with little subcue tissue

Question 6

how does a pressure wound develop

Answer 6

deep to superficial according to the following steps 1. increased interstitial fluid pressure 2. decreased arteriole circulation 3. capillary collapse leading to fluid leakage 4. edema 5. tissue autolysis 6. decreased nutrients and oxygen to tissues

Question 7

what are the four phases culminating in pressure ulcer development

Answer 7

inflammatory response > ischemia > necrosis > ulceration

Question 8

with regards to pressure ulcer development, whats the difference between blanchable and nonblanchable erythema

Answer 8

blanchable - damage is reversible with about 24 hours of pressure relief non blanchable - first sign of pressure injury formation

Question 9

define friction as it relates to ulcerations

Answer 9

epidermis is rubbed, pulled across, or abraded from the deeper layers parallel to the force

Question 10

define shear

Answer 10

a combination of force and friction

Question 11

how does moisture impact wound development on healthy integument?

Answer 11

prolonged moisture exposure can cause maceration making the skin less resistant to mechanical stress

Question 12

where are the common sites of pressure injuries in sitting

Answer 12

heels, IT, sacrum, elbows, spinous processes, scapulae

Question 13

what are the characteristics of stage 1 pressure injuires

Answer 13

• skin intact (can run your hand across and not feel a difference)
• non-blanching redness or darker pigmented skin
• sensory changes
• purple or maroon may indicate a deep tissue pressure injury

Question 14

what are the characteristics of a stage 2 pressure injury

Answer 14

• partial thickness with exposed dermis
• viable, pink/red, moist, or serum filled blister

Question 15

what is MASD and how do you classify it

Answer 15

moisture associated skin damage - cannot stage classify

Question 16

what is IAD and how do you classify it

Answer 16

incontinenece associated dermatitis - cannot stage classify it

Question 17

what is MARSI and how do you classify it

Answer 17

medical adhesive related skin injury - cannot stage classify it

Question 18

what are the characteristics of a stage 3 pressure injury

Answer 18

• full thickness loss of skin
• rolled edges
• fat, granulation tissue, slough, and eschar all may be visible

Question 19

what makes a pressure injury unstageable

Answer 19

slough or eschar obscuring the extent or depth of tissue loss - once removed, the wound will be either stage 3 or 4 exclusively

Question 20

what are the characteristics of a stage 4 pressure injury

Answer 20

• full thickness
• palpable fascia, bone, tendon, ligament, or muscle
• slough or eschar may be present

Question 21

what condition is associated with bone exposure due to pressure injury

Answer 21

osteomyelitis

Question 22

at which of the 4 pressure injury stages may we see epibole, undermining, or tunneling

Answer 22

stage 4

Question 23

where are we most likley to see pressure injuries in proned patients

Answer 23

knees, ASIS, clavicle, facial bones

Question 24

a patient has had a R TKA, which heel (R or L) are we most likely to see the development of a PI

Answer 24

the operative leg (R)

Question 25

what are the six domains of the Braden Scale for pressure injuries

how is the Braden Scale generally interpreted

Answer 25

1. sensory
2. moisture
3. activity
4. mobility
5. nutrition
6. friction/shear

the lower the overall score, the higher likelihood of pressure injury

Question 26

what are the three domains of the PUSH Tool and what is its major drawback according to Michelle

Answer 26

1. LxW
2. Exudate amount
3. tissue type

it doesn’t account for depth or undermining

Question 27

what are the five pressure injury prevention concepts for bed-bound individuals

Answer 27

1. reposition q2hrs with a 30 deg turn
2. use pillows and wedges to keep the bones off the bed
3. minimize HOB elevation to prevent shear
4. lift instead of slide to move the patient
5. check equipment frequently

Question 28

how would you use a doughnut in the acute setting to manage pressure injuries

Answer 28

trick question, do not use doughnuts because they can increase ischemia, venous congestion, and/or edema

Question 29

what is a group 1 support surface

Answer 29

overlays and reactive therapeutic mattress replacements

Question 30

what is a group 2 support surface

Answer 30

active powered mattress replacements

Question 31

what is a group 3 support surface

Answer 31

air-fluidized beds

Question 32

what is the difference between a reactive therapeutic mattress and a active powered mattress

Answer 32

RTM (group 1) only reacts to the patient when the patient is in the bed and a APM (group 2) can react without patient contact

Question 33

what are the 3 pressure injury prevention concepts for chair-bound individuals

Answer 33

1. q15-30min for at least 1 min
2. use pressure reducing devices
3. consider wheelchair Rx (tilt in space)