Question

Q :1 List three additional assessments or reviews (not wound assessments) that enable a holistic approach to wound care. e.g. Braden's score

Q:2 Pressure Injury Prevention
Hospitalised clients are prone to development of pressure injuries. Australian Standards for Safety and Quality stress the importance of pressure injury prevention in hospitalised clients.

Q:3 What are the different stages of pressure injury? Explain each stage briefly (10-20 words).

Stages

Description

35.1)     Stage I

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35.2)     Stage II

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35.3)     Stage III

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35.4)     Stage IV

What causes pressure injury? List down at least 4.

Answer 1

Q:1) answer :

• Waterlow scale
• Norton scale
• Pieper pressure ulcer knowledge test.

Q:2) Prevention of pressure injury :

• Understand risk factors : identifying the risk patients is a critical component of pressure injury prevention
• Positioning and repositioning : patient at risk should be suitably repositioned to redistribute pressure.
• Use protective barriers between the device and the patient.
• Skin care : keep skin clean and dry, do not vigorously rub or massage the patients skin, use water based emollients to maintain skin hydration .
• Nutrition :nutrition can major impact on skin health. Albumin level must be kept within normal range to ensure the skin integrity and prevent tearing.

Q. 3) Different stages of pressure ulcer:

Pressure ulcer can progress in 4 stages such as stage I, stage II, stage III and stage IV based on the level of tissue damage.

35.1) Stage I : This is the mildest stage. These pressure injury only affects the upper layer of the skin. Pain, burning or itching are the common symptoms.

35.2) Stage II : In this stage the sore digs deeper below the surface of your skin. Your skin is become broken and leaves an open wound. The area becomes swollen warm and or red, looks like a pus filled blister.

35.3) Stage III : The sores can be gone through the second layer of the skin in to the fat tissues. The sore looks like a crater and many have a bad odor. It may shows the signs of infection .

35.4) Stage IV: This stage is most serious . Some may have affect your muscles and ligaments. The sore is deep and big. Skin has turned black and shows signs of infection. You may be able to see tendons, muscles and bone.

Causes of pressure injury :

1. Constant Pressure
2. Friction
3. Shear
4. Immobility