Pressure Ulcers

Question 1

Pressure ulcers

Answer 1

Any lesions caused by unrelieved external pressure resulting in occlusion of blood flow, tissue ischemia and cell death.

Question 2

Stage 1 pressure injury

Answer 2

Intact skin with erythema that does not blanch.
Color changes do not include purple or maroon discoloration.

Question 3

Stage 2 pressure injury

Answer 3

Partial thickness loss of skin with exposed dermis.
Would bed is viable, pink or red, moist and may also present as an intact or rupture serum filled blister.
Should not be used to describe moisture associated skin damage (MASD).

Question 4

Stage 3 pressure injury

Answer 4

Full thickness skin loss, adipose tissue is visible in the ulcer and granulation is present.
Slough and/or eschar may be visible. If this slough or eschar obscures the extent of tissue loss then it would be an unstagable pressure injury.

Question 5

Stage 4 pressure injury

Answer 5

Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in ulcer.

Question 6

Unstageable pressure injury

Answer 6

Obscured full thickness skin and tissue loss.
The extent of tissue damage within the ulver cannot be confirmed because it is obscured by slough or eschar.
If slough or eschar removed, a stage 3 or 4 pressure injury will be revealed.

Question 7

Deep tissue pressure injury

Answer 7

Persistent non blanchable deep red, maroon or purple discoloration.
Intact or non intact skin with localized areas.

Question 8

Management of pressure injuries

Answer 8

Cleans with normal saline.
Debride w/ wet to moist dressing.
Dressing depends on wound characteristics: if the wound is weaping, use a hydrocolloid dressing.