Week 1 - Pressure Injuries

Question 1

What is a Pressure Injury?

Answer 1

A pressure injury is localised damage to the skin and underlying soft tissue that’s usually, but not always, over a bony prominence

Question 2

Who is more at risk to getting a pressure injury?

Answer 2

More at risk of a pressure injury if they are sick, fragile, cannot mobilise easily or have poor food and fluid intake

Question 3

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

Answer 3

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

Question 4

Describe key points to the acronym Surface and devices to prevent pressure injuries

Answer 4

• Moving the person when they are uncomfortable or have a loss of feeling is essential to prevent pressure injuries
• keep the patient’s backrest to less than 30 degrees.
• Important to prevent a person from slipping in bed, which can cause shearing of the skin.
• Raising the head of the bed without a knee brake causes friction and shear
• Pillows, cushions and mattresses can make a significant impact on reducing pressure injuries
• Re-positioning needs to be regular
• Catheters, nasal prongs, splints and casts can cause pressure. Careful positioning is essential

Question 5

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

Answer 5

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

Question 6

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

Answer 6

• 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 7

What is the knee break technique?

Answer 7

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 8

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

Answer 8

• 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 9

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

Answer 9

• 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 10

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

Answer 10

• 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 11

How many stages of pressure injuries are there?

Answer 11

4 stages

• Stage 1
• Stage 2
• Stage 3
• Stage 4

Question 12

Characteristics of a stage 1 pressure injury?

Answer 12

• 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 13

Characteristics of a Stage 2 pressure injury

Answer 13

• 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 14

What stages do nurses confuse with deep tissue pressure injuries?

Answer 14

Stages 1 and 2

Question 15

What are deep tissue pressure injuries?

Answer 15

Localised areas that:

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

Question 16

How can deep tissue injuries present?

Answer 16

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 17

Characteristics of a stage 3 pressure injury

Answer 17

Full-thickness loss of skin and has fat visible in the wound. May also have granulation tissue, slough or eschar, but the slough and/or eschar don’t obscure the extent of tissue destruction involved in the wound.

Question 18

Characteristics of a Stage 4 pressure injury

Answer 18

Muscle, fascia, cartilage, tendon, ligament or bone is observable or directly palpable in the wound, it’s a stage 4 pressure injury

Question 19

What assessment do we use for pressure injuries in adults?

Answer 19

Braden scale

Question 20

What are some additional approaches to prevent hospital-acquired pressure injuries?

Answer 20

Turning and repositioning the patient frequently enough to relieve pressure to bony prominences.

Padding bony prominences, such as placing a pillow between the knees and ankles when the patient is side-lying

Keeping the elevation of the head of the bed in the lowest position that’s medically appropriate to reduce shear forces on the sacrum

ensuring the bariatric patient has a support surface that gives him or her adequate space to turn from side to side

Floating the heels off the mattress with heel lift boots or pillows

Maintaining pH of the skin with the use of pH-balanced skin cleaners, followed by skin moisturisers and protectants

Containing feral and urinary incontinence to the greatest extent possible

Optimising the patient’s nutritional status

Providing a pressure redistribution mattress and chair for high-risk patients and those with preexisting pressure injuries as appropriate

Assessing under medical devices for tissue breakdown; pad the areas impacted by such devices when needed

Collaborating with the multidisciplinary team to optimise care interventions

Question 21

What three factors determine the stage of a pressure injury?

Answer 21

• Fluid
• Colour
• Exposed or directly palpable tissue

Question 22

Characteristics and what you are looking for with fluid for a pressure injury?

Answer 22

• Is there fluid in the wound? If so, what type?
  - An intact or ruptured fluid-filled blister corresponds to a stage 2 pressure injury
  - An intact or ruptured blood-filled blister corresponds to a deep tissue pressure injury

Question 23

Characteristics and what you are looking for with colour for a pressure injury?

Answer 23

• What colour is the wound?
• Reddened, intact tissue that doesn’t blanch indicates stage 1 pressure injury
• Pink or red tissue that’s moist and superficial indicates stage 2 pressure injury
• Dark red, purple, or maroon tissue with or without the overlying skin indicates a deep tissue pressure injury

Question 24

Characteristics and what you are looking for with exposed or directly palpable tissue for a pressure injury?

Answer 24

• What tissues do you see or feel in the wound bed?
• Slough or eschar obscuring the wound bed so that you can’t determine the level of tissue destruction is an unstageable pressure injury
• If adipose tissue is visible in the wound (globular, yellow appearance and/or granulation tissue) then you know it is a stage 3 pressure injury
• Any wound with the deeper tissues exposed or palpable (fascia, muscle, ligament, tendon, cartilage or bone) is a stage 4 pressure injury