Pressure Injuries
An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage 1 pressure injury forming on the client's sacrum. Which action by the nurse is appropriate to reduce the progression of this injury? A) Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side. B) Apply a heat lamp to the area to increase circulation. C) Apply a dry dressing to the pressure injury. D) Maintain the head of the bed at a 45-degree angle.
Answer: A Keeping the head of the bed at an angle of 30 degrees or less decreases pressure on the sacrum. An angle of 45 degrees would be too severe and could exacerbate pressure injury formation on the sacrum. Dry dressings are not indicated with this stage of pressure injury. Heat lamps are no longer used in the treatment of pressure injuries because they do not provide therapeutic benefit.
Softening of the skin as a result of prolonged wetting or soaking is also referred to as A) maceration. B) debridement. C) excoriation. D) shearing.
Answer: A Maceration involves softening of the skin due to prolonged wetting or soaking. Excoriation is loss of the superficial layers of the skin. Debridement is the removal of necrotic material from a wound. Shearing occurs when one layer of tissue slides over another.
When planning care for a client at risk for developing pressure injuries, which intervention(s) should be included? Select all that apply. A) Initiate a frequent toileting schedule. B) Raise the client's heels off the bed. C) Turn the client every 4 hours. D) Use inflatable doughnut-style devices to reduce pressure on the sacrum. E) Massage pressure areas with lotion every 4 hours.
Answer: A, B Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and the potential for skin breakdown. The client's heels should be raised off the bed to remove pressure on this area of the body. The client should be turned at least every 2 hours. Massaging pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, because they increase pressure and reduce perfusion to affected areas.
What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4
Answer: B A stage 2 pressure injury is characterized by partial-thickness skin loss involving the dermis. It presents as a shallow open ulcer with a viable, moist wound bed that is red or pink. Granulation tissue, slough, and eschar are not present. A stage 2 injury may also present as an intact or open serum-filled blister.
A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate? A) "I will need to get an order from the physician." B) "Using the doughnut can cause skin breakdown." C) "You will need to wait until discharge, then use the doughnut at home." D) "I will obtain the device for you."
Answer: B Use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened with use of the device, but this is due to the loss of sensation. Use of a doughnut-style device should be avoided whether at the hospital or at home.
A client has a pressure injury on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use? A) Partial-thickness loss of dermis B) Nonblanchable erythema C) Suspected deep tissue injury D) Full-thickness tissue loss
Answer: C A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Nonblanchable erythema refers to a stage 1 pressure injury. Partial-thickness loss of dermis refers to a stage 2 pressure injury. Full-thickness tissue loss refers to stage 3, stage 4, and unstageable pressure injuries.
A client has a documented stage 3 pressure injury on the right hip. Which nursing diagnosis is most appropriate for this client? A) Impaired Skin Integrity B) Risk for Injury C) Impaired Tissue Integrity D) Ineffective Peripheral Tissue Perfusion
Answer: C Because a stage 3 pressure injury involves tissue, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure injuries result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity involves the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury, so Risk for Injury does not apply.
The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor? A) The rubber doughnut pressure relief device was not delivered by central supply. B) The client's serum albumin increased over the last month. C) A right side-back-left side-back turning schedule was used. D) Nurses did not document disinfection of the wound with alcohol at each dressing change.
Answer: C Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.
The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? Select all that apply. A) Age 54 B) Body temperature within normal limits C) Low serum albumin level D) Continence of urine and stool E) Prescribed bedrest
Answer: C, E Risk factors for pressure injury development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure injury development. Although advanced age increases the risk of pressure injuries, this client is only 54 years old. Finally, normal body temperature does not increase the client's risk for pressure injury development.
Which of the following clients would be the most appropriate candidate for autolytic debridement? A) A 47-year-old client with a stage 2 pressure injury B) A 68-year-old client with a suspected deep tissue injury C) A 71-year-old client with a stage 1 pressure injury D) A 59-year-old client with a stage 3 pressure injury
Answer: D Debridement, regardless of type, is typically reserved for pressure injuries with full-thickness tissue loss. This includes stage 3 pressure injuries, stage 4 pressure injuries, and (in some cases) unstageable pressure injuries. Thus, only the client with a stage 3 injury would be an appropriate candidate.
A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. Which response by the nurse is appropriate? A) "I will need to obtain an order from the healthcare provider to perform a massage." B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care." C) "I will record these findings in the medical record." D) "Massage may actually cause more harm to a potentially compromised area of skin."
Answer: D Redness may indicate the presence of a stage 1 pressure injury. Evidence suggests that massage over bony prominences like the coccyx can cause or worsen deep tissue trauma in patients at risk for a pressure injury. Massage should thus be restricted when problems are noted. Even when appropriate and therapeutic for a client, massages do not require a healthcare provider's order.
A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility's older adult clients are at elevated risk for pressure injuries. Which response is best? A) "As people age, their epidermis becomes more elastic. This increased elasticity makes older adults' skin more susceptible to damage." B) "As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries." C) "Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity." D) "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity."
Answer: D Several factors put older adults at increased risk for pressure injuries; these include loss of lean body mass; generalized thinning of the epidermis; decreased strength and reduced elasticity of the skin; and diminished venous and arterial flow due to aging vascular walls. Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands also increases the risk for impaired skin integrity in older adults. Although excess body heat is a risk factor for pressure injuries, older adults tend to have lower average body temperatures than younger clients.
An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown? A) Using the bed sheet to slide the client up in bed B) Placing the bed in reverse Trendelenburg position C) Using the client's arms to pull the client up in bed D) Lifting the client, using the client's legs and arms for assistance
Answer: D The client is of advanced age and has poor skin turgor. Both of these factors put the client at increased risk for alterations in skin integrity, including damage due to shearing forces. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client up in bed may cause skin shearing. Sliding the client on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg position will not facilitate appropriate positioning of the client in the bed.
A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client? A) Clean the pressure injury as needed. B) Use hydrogen peroxide for chemical debridement of wound bed as needed. C) Maintain the head of the client's bed at 30 degrees. D) Avoid placing the client in the side-lying position.
Answer: D The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.