Question

35)    What are the different stages of pressure injury? Explain each stage briefly (10-20 words).

Stages

35.1)     Stage I Description

35.2)     Stage II Description

35.3)     Stage III Description

35.4)     Stage IV   Description

36)    Based on the Flow chart for prevention and management of Pressure injuries by AWMA, what are the nursing considerations in prevention and management of pressure injury? Use the table to write strategies. Write a minimum of 3 strategies for each care realm.

Care realm

36.1)     Mobility Nursing considerations/ strategies

36.2)     Nutrition Nursing considerations/ strategies

36.3)     Reducing friction and shear Nursing considerations/ strategies

36.4)     Relieving pressure Nursing considerations/ strategies

36.5)     Wound management Nursing considerations/ strategies

36.6)     Skin Moisture management Nursing considerations/ strategies

37)   Wound Healing
Briefly describe the following factors causing delayed wound healing (10-30 words each)

37.1)   AGE

37.2)   ISCHAEMIA

37.3)   INFECTION AND INFLAMMATION

Answer 1

Ans) 35) Pressure ulcers are caused by pressure against your skin for a long period of time. This pressure causes decreased circulation and skin breakdown. Your physical therapist can work with your nursing team to help prevent pressure ulcers from forming. Methods of pressure ulcer prevention may include:

• Frequent position changing
• Using pressure-relieving pads over bony prominences
• Education for nurses, doctors and family members about the importance of frequent movement to prevent skin breakdown.

- Pressure ulcers are categorized into four stages by the National Pressure Ulcer Advisory Panel depending on the level of tissue involvement or depth of the sore.

- The tissue being referred to includes the skin and underlying dermis, fat, muscle, bone, and joint. Knowing the appropriate stage assists in the prognosis and management of the ulcer.

35.1).Stage One Pressure Ulcer:

- Stage one pressure ulcers are characterized by erythema of intact skin that does not blanch when pressed upon. The skin may appear red and feel warm to touch.

- In individuals with darker skin, discoloration, warmth, edema, induration, or hardness may be indicators of a stage one pressure ulcer formation.

- Recovery time for a stage one pressure ulcer is typically three to four days if treatment is started right away. If the pressure is not removed from the area, a stage one pressure ulcer may progress to a stage two ulcer.

35.2) Stage Two Pressure Ulcers:

- Stage two pressure ulcers involve partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center. It may be warm to the touch and red.

- Expect a stage two bed sore to last for approximately four days to three weeks.

- To relieve pressure from the skin in this area by proper positioning, frequent moving, or padding or the ulcer may progress to stage three.

35.3) Stage Three Pressure Ulcers:

- Stage three decubitus ulcers are full thickness skin loss involving damage or necrosis of subcutaneous tissue (the tissue below the skin) that may extend down to, but not through, underlying fascia.

- The sore presents clinically as a deep crater with or without undermining of adjacent tissue. The area surrounding the sore may be red and hard, and warmth may be palpated throughout.

- There may be pus or drainage from the sore, and a foul smell may also be noted. This type of ulcer certainly opens your body up to infection of the skin and underlying tissue.

- The recovery time of a stage three pressure ulcer may take one to four months with proper treatment.

35.4) Stage Four Pressure Ulcers:

- The stage four pressure ulcer presents as full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

- This is the most severe of pressure ulcer formation and is most difficult to treat. These ulcers require strict adherence to a pressure relieving schedule and a wound care team to fully manage the lesions.

- In stage four ulcers, there may be a deep crater in the sore with significant drainage and pus. A foul odor may be present, and the tissue surrounding the area may be dark purple or black.

3.4) Stage four pressure ulcers are a serious problem, as they open your body up to bacteria and infection. Recovery time for this type of ulcer can extend from two to six months, and they require frequent monitoring and care from a wound care team to ensure a successful outcome.