CNST Chapter 39: Pressure Injury Prevention and Care

After teaching a home caregiver how to manage a pressure ulcer, the nurse realizes that further education is needed when the caregiver says: a. "I will be sure to reposition her frequently and keep her off of the pressure ulcer." b. "I will wash the pressure ulcer with saline and report any changes in the drainage." c. "I know that a thick, black covering will protect the pressure ulcer from getting worse." d. "I will let you know if the pressure ulcer starts to smell rotten."

C Black tissue in a pressure ulcer is eschar, a necrotic tissue that covers a section of the ulcer and prevents effective assessment. If the caregiver makes this statement additional education is needed. The other statements indicate that the caregiver understands how to care for pressure ulcers.

A _______________ is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

pressure ulcer A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

When skin layers adhere to the linens and deeper tissue layer move downward, ________ damage occurs.

shear Shear damage is caused when pressure holds one layer of skill in place while the deeper layer is forced downward as may happen when turning or moving in bed. This force causes reduced blood flow to the tissues.

In a patient with a stage II pressure ulcer, the nurse describes the wound as: a. superficial blistering. b. nonblanchable redness. c. loss of skin without bone exposure. d. loss of skin with exposed muscle.

A A stage II pressure ulcer is defined by partial-thickness loss presenting as a shallow open ulcer with a red to pink wound bed, without slough. It also may present as an intact or open/ruptured serum-filled blister. It usually presents as a shiny or dry shallow ulcer without sloughing or bruising. The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage III pressure ulcers involve full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed.

Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to: a. 16. b. 18. c. 20. d. 24.

A Less than or equal to 16 is the risk cut score for the general population when the Braden Scale is used. Less than or equal to 18 is the risk cut score for older adults and black or Latino patients when the Braden Scale is used.

The patient with a nasogastric (NG) tube in place may experience skin breakdown: a. in the nose. b. on the tongue. c. behind the ears. d. around the lips.

A NG and oxygen cannulas can cause pressure on the nares, leading to pressure ulcers. Skin breakdown around the lips and tongue may result from oral airways or endotracheal (ET) tubes. Skin breakdown behind the ears may result from pressure from the oxygen cannula or the patient's pillow.

The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx. The patient complains of pain at the site, and the site feels cooler than the areas immediately around the site. The nurse recognizes that this patient has developed: a. a stage I pressure ulcer. b. a stage II pressure ulcer. c. an unstageable pressure ulcer. d. deep tissue injury.

A The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage II pressure ulcers are defined by partial-thickness loss that presents as a shallow open ulcer with a red or pink wound bed, without slough. They also may present as intact or open/ruptured serum-filled blisters. They usually present as shiny or dry shallow ulcers without sloughing or bruising. Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore the stage, cannot be determined. Deep tissue injury usually is characterized by purple or maroon localized areas of discolored intact skin or blood-filled blisters caused by damage to underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared with adjacent tissue. The wound may further evolve and become covered by thin eschar.

The nurse knows that which of the following factors contribute to the development of pressure ulcers? (Select all that apply.) a. Friction and shear b. Immobility c. Poor nutrition d. Moisture and ammonia e. Uncontrolled pain

A, B, C, D Factors such as incontinence, friction and shear, immobility, loss of sensory perception, reduced level of activity, and poor nutrition contribute to pressure ulcer formation. Moisture and ammonia from incontinence soften the skin, allowing the skin to become susceptible to breakdown. Uncontrolled pain does not contribute to the development of pressure ulcers.

Patients are at risk for developing pressure ulcers on which areas of the body? (Select all that apply.) a. Coccyx b. Nares c. Ears d. Genitalia

A, B, C, D The most common sites of pressure ulcers are the sacrum, coccyx, ischial tuberosities, greater trochanters, elbows, heels, scapulas, iliac crests, and lateral and medial malleoli (Pieper, 2007). Pressure ulcers can occur on any area of skin subjected to pressure. Nonbony locations in which pressure ulcers can occur include the nares, usually related to pressure caused by nasogastric (NG) tubes or oxygen cannulas; the ears, resulting from an oxygen cannula; and the genitalia, with ulcers resulting from Foley catheter tension.

The nurse is aware that pressure ulcers can occur: (Select all that apply.) a. from any position that causes soft tissue compression. b. because of lack of blood flow (ischemia). c. only in bed bound patients. d. in as little as 90 minutes.

A, B, D Pressure ulcers occur from any position that causes soft tissue compression. Compression of soft tissue interferes with blood flow to the tissue; if this compression continues for a prolonged time, the tissue dies from lack of blood flow, also known as ischemia. This pressure, if not relieved, can cause irreversible tissue damage in as little as 90 minutes. It is quite possible for an individual to develop a pressure ulcer even if not confined to bed.

The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer? a. The patient who is bedridden, but who turns himself randomly b. The patient whose Braden Scale score is 8 c. The patient who can ambulate to the bathroom independently d. The patient whose Braden Scale score is 18

B Given the overall score on the Braden Scale, the patient will fall within one of these categories: mild risk, 16 to 18; moderate risk, 13 to 14; or high risk, 9 or less. Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient's ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot.

The nurse is planning care for her patient who has a stage II pressure ulcer. Care should include which of the following? (Select all that apply.) a. A heat lamp to dry the wound b. Application of topical antibiotics c. Nutritional assessment d. Maintaining moisture in the wound

B, C, D The treatment plan for a patient with a pressure ulcer must include elimination or reduction of the factors that have caused the pressure ulcer. A moist wound environment supports the growth of new tissue. If the wound is not free of necrotic tissue, you need to choose topical wound care that will cleanse the wound bed of devitalized tissue. Treat infection both systematically and topically. Wound healing in a patient with a pressure ulcer progresses if the patient has adequate nutritional status as well as control over preexisting conditions such as diabetes and cardiovascular and pulmonary disease

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention? a. Edema in the sacrum b. Skin texture c. Skin temperature d. Pallor or mottling of the skin

C Darkly pigmented skin does not always have visible blanching. Its color differs from that of surrounding skin. Skin temperature changes may be an important early indicator of a stage I pressure ulcer. Edema is not an initial indication of a pressure ulcer. Do not massage any reddened or discolored pressure points. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels. Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin.

In a long-term care agency, how often should the nurse reassess a patient for risk of a pressure ulcer? a. Every 1 to 2 days b. Every time the nurse sees the patient c. Weekly for the first few weeks of stay d. Monthly for the first 4 months of stay

C In a long-term care agency, the patient is assessed every week for 4 weeks and then quarterly, or whenever the patient's condition changes. An assessment schedule of every 1 to 2 days would be more appropriate for acute care than in the long-term care setting. The patient is not reassessed for risk in the long-term setting every time the nurse sees the patient. The new patient in long-term care is reassessed weekly rather than monthly after he is admitted.

When evaluating a patient, the nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated. The nurse should: a. obtain a wound culture. b. apply pressure-reducing devices. c. use dressings with increased moisture absorption. d. monitor the patient for systemic signs and symptoms.

C Select a dressing that has increased moisture-absorbing capacity. Dressings that increase moisture absorption will result in dryer skin that is less macerated. A wound culture is not indicated for macerated skin unless an increase in drainage or development of necrotic tissue occurs. Pressure-reducing devices are not indicated for macerated skin. Macerated skin is a local reaction; the patient would not need systemic monitoring unless the pressure ulcer extended beyond the original margins.

The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound. How would the nurse classify this ulcer? a. Stage III pressure ulcer b. Stage IV pressure ulcer c. Wound that cannot be staged d. Stage II pressure ulcer

C To correctly stage a pressure ulcer, the nurse must be able to see the base of the wound. Therefore, pressure ulcers that are covered with necrotic tissue cannot be staged until the eschar has been debrided and the base of the wound is visible. Until debridement occurs, the ulcer should be documented as unstageable.

A patient with anemia is at risk for developing pressure ulcers as a result of which of the following? a. Increased sedation b. Edematous tissues c. Reduced tensile strength d. Diminished oxygen to the tissues

D Decreased hemoglobin reduces the oxygen-carrying capacity of the blood and the amount of oxygen available to the tissues, thus increasing the risk for pressure ulcers. Anemia does not cause increased sedation, edematous tissue, or reduced tensile strength

A nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does it indicate if the wound bed has granulation in it? a. Wound needs debridement b. The presence of significant infection c. Colonization by bacteria d. Movement toward healing

D The presence of granulation tissue signifies a movement toward wound healing. Black tissue is necrotic tissue. A wound with a high percentage of black tissue will require debridement. Yellow tissue or slough tissue indicates the presence of infection or colonization

The removal of devitalized tissue in a wound is known as ______________.

debridement If the tissue in the wound is devitalized, consider debridement, which is the removal of devitalized tissue. Debridement is accomplished by selecting a dressing and using enzyme preparations or surgical or laser techniques.