Pressure Injury Practice Questions with Answers and NCLEX® Review

Introduction to Pressure Injuries

There are six stages of pressure injuries based on the extent of tissue damage, ranging from Stage 1 to Stage 4, as well as two additional stages, suspected deep tissue injury and unstageable, which can occur.

It is essential to assess pressure injuries on admission to a facility and daily to determine their stage and to initiate appropriate interventions to promote healing and prevent further damage.

Pressure Injury Pathophysiology

Ischemia and tissue necrosis as a result of sustained pressure over a prolonged period of time results in damage to the skin and/or the underlying tissue over a bony prominence. This is most

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common with immobile clients who have not turned adequately or who have a medical device that causes irritation such as oxygen tubing.

Most common areas include:

•  lower back and buttocks (sacrum and coccyx)
•  heels and ankles
•  hip bones
•  shoulder area and elbows

Pressure Injury Causes and Risks

• Immobility
• Incontinence
• Poor nutrition
• Diabetic neuropathy
• Liver cirrhosis = Low Albumin

Stages of Pressure Injuries

Stage 1: One Layer of Damage (Epidermis)

Epidermis injuries are the earliest and least severe stage of pressure injury. This stage is characterized by red skin that is non-blanchable and not broken over a bony prominence. 

Stage 2: Two Layers of Damage

This stage indicates an open wound, affecting both the epidermis and dermis. The wound bed is red or pink, and shiny or dry.

The pressure injury is characterized by partial thickness skin loss that involves the epidermis and/or dermis. The wound bed is visible, and the area may appear as a blister or shallow crater.

Stage 3: Three Layers of Damage (Epidermis, Dermis, and Subcutaneous)

This stage is characterized by full-thickness skin loss into the subcutaneous fat. The wound may tunnel under the edges of the wound bed (appearing as a deep crater).

The pressure injury is characterized by full-thickness skin loss that involves damage or necrosis of subcutaneous tissue, but not extending to the underlying fascia. 

Stage 4: Four Layers of Damage

This wound extends all the way down into muscle, bone, or tendon.

The pressure injury is the most severe form of pressure injury. It’s characterized by full-thickness skin and tissue loss, extending through the fascia and often resulting in extensive tissue destruction, such as muscle, bone, and tendons.

The Eschar Stage

This is an area of intact skin with a dark, purple, or maroon discoloration or a blood-filled blister, which indicates damage to underlying soft tissue. The area may be painful, firm, mushy, or boggy to the touch. This stage is characterized by dead necrotic tissue, and may rapidly progress to deeper stages.

Deep Tissue Injury (DTI)

The fatty tissue is injured below the skin (dark purple, and sometimes open wound) at this point. 

An unstageable pressure injury is covered by eschar or slough, which makes it difficult to determine the extent of tissue damage. The area may be black, brown, or yellow.

Pressure Injury Treatment & Nursing Interventions

• Assess skin and document on admission and every shift or daily.
• Keep the client clean and dry with less layers under them.
• Turn the client every two hours.
• Provide special mattresses to relieve pressure.
• Nutrition: Protein and Fluids (2 – 3 L / day)
  • Urine output 30 mL/hr or Less = Kidney Distress
• Monitor for:
  • Stage, size, and color

Sources

https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=zm2442