Week 3 Content

Question 1

What is a pressure injury?

Answer 1

A localised injury to the skin and / or underlying tissue.

Question 2

Why focus on pressure injuries?

Answer 2

Nurses need to understand the risk of pressure injuries in order to implement strategies to prevent them - in most cases they are preventable.

Question 3

How do pressure injuries develop?

Answer 3

From external pressure or friction, which either compress or injure the blood vessels.

Question 4

What are some risk factors of pressure injuries?

Answer 4

• Extreme in young people and the elderly
• Immobility/ inactivity
• Impaired sensory perception
• Malnutrition or dehydration
• Moisture
• Plastic or vinyl surfaces
• Obesity
• Poor skin condition

Question 5

Explain the 6 stages of pressure injuries?

Answer 5

Stage 1 = Intact skin with non- blanchable erythema.
Stage 2 = Partial thickness loss of dermis, presenting as a shallow open wound
Stage 3 = Full thickness of tissue loss
Stage 4 = Full thickness of tissue loss with exposed bone, tendon or muscle.
Stage 5 = Unknown depth
Stage 6 = Suspected deep tissue injury

Question 6

When do you bed bath a patient?

Answer 6

• Can’t immobilise
• Too many pressure wounds and lacerations → safer to bed bath
• Can’t get dressings wet
• Falls risk

Question 7

What are examples of elimination/toileting?

Answer 7

• Bed pan
• Slipper pan
• Urine bottle
• Incontinent pad
• Toilet commode chair

Question 8

What are factors of falls risk patients?

Answer 8

• Opioids = drowsy medication
• Blind
• Medical condition e.g. stroke or parkinsons
• Sudden drop in blood pressure
• Gate = walking funny