|
| A) | also referred to as venous insufficiency. | ||
| B) | caused by excessively soft chairs or beds. | ||
| C) | impaired circulation, usually in the extremities. | ||
| D) | localized areas of injury to the skin or underlying soft tissue. |
According to the 2019 NPIAP guideline, pressure injuries are localized areas of injury to the skin or underlying soft tissue caused by sustained pressure or pressure in combination with shear or friction, including those related to a medical or other device. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the tissue. The injury can present as intact skin or an open ulcer and may be painful. Pressure injuries commonly develop in association with debilitating illness and injury that lead to immobility and gravity-dependent pressure over boney prominences, such as the sacrum, hip, heel, or ankle [1,3].
| A) | 15% | ||
| B) | 25% | ||
| C) | 65% | ||
| D) | 95%. |
An estimated 95% of pressure injuries occur on the lower part of the body, with approximately 70% in the hip and buttocks area and 15% to 25% in the lower extremities [8]. There is a two to six times greater mortality risk for patients who develop pressure ulcers [8,9]. In acute care hospitals, patient risk for acquiring a pressure injury is estimated to range from 2.7% to 29% [1,8].
| A) | partial thickness skin loss. | ||
| B) | nonblanchable redness of intact skin. | ||
| C) | full-thickness skin and tissue loss with fat visible. | ||
| D) | full-thickness skin and tissue loss with muscle and bone visible. |
In 2014, the NPUAP (now the NPIAP) and the European Pressure Ulcer Advisory Panel (EPUAP) developed a common international definition and description system for pressure ulcers. As noted, the NPUAP further revised some of these definitions and staging efforts to reduce confusion and clarify terminology in 2019. The revised NPIAP guidelines for staging a pressure injury are [2,6]:
Stage 1 Pressure Injury—Nonblanchable erythema of intact skin: Intact skin with a localized area of nonblanchable erythema. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include maroon or purple discoloration, as this may indicate deep pressure injury. Changes may appear differently in darkly pigmented skin.
Stage 2 Pressure Injury—Partial-thickness skin loss with exposed dermis: The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (e.g., skin tears, burns, abrasions).
Stage 3 Pressure Injury—Full-thickness skin loss: These wounds display full-thickness skin loss with adipose visible in the ulcer and granulation tissue and epibole (rolled wound edges) often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomic location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, it is considered an unstageable pressure injury.
Stage 4 Pressure Injury—Full-thickness skin and tissue loss: Wounds of this stage have full-thickness skin and tissue loss, with exposed or directly palpable fascia, tendon, muscle, ligament, cartilage, or bone, often with sloughing or eschar on the wound bed and epibole, undermining, tunneling, and fistula formation. Depth varies by anatomic location. If slough or eschar obscures the extent of tissue loss, it is considered an unstageable pressure injury.
Unstageable Pressure Injury—Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is completely covered by slough and/or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
Deep Tissue Pressure Injury—Persistent non-blanchable deep red, maroon, or purple discoloration: This wound is characterized by intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, stage 3, or stage 4). This term does not describe vascular, traumatic, neuropathic, or dermatologic conditions.
| A) | stage 2. | ||
| B) | stage 4. | ||
| C) | unstageable. | ||
| D) | deep tissue injury. |
In 2014, the NPUAP (now the NPIAP) and the European Pressure Ulcer Advisory Panel (EPUAP) developed a common international definition and description system for pressure ulcers. As noted, the NPUAP further revised some of these definitions and staging efforts to reduce confusion and clarify terminology in 2019. The revised NPIAP guidelines for staging a pressure injury are [2,6]:
Stage 1 Pressure Injury—Nonblanchable erythema of intact skin: Intact skin with a localized area of nonblanchable erythema. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include maroon or purple discoloration, as this may indicate deep pressure injury. Changes may appear differently in darkly pigmented skin.
Stage 2 Pressure Injury—Partial-thickness skin loss with exposed dermis: The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (e.g., skin tears, burns, abrasions).
Stage 3 Pressure Injury—Full-thickness skin loss: These wounds display full-thickness skin loss with adipose visible in the ulcer and granulation tissue and epibole (rolled wound edges) often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomic location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, it is considered an unstageable pressure injury.
Stage 4 Pressure Injury—Full-thickness skin and tissue loss: Wounds of this stage have full-thickness skin and tissue loss, with exposed or directly palpable fascia, tendon, muscle, ligament, cartilage, or bone, often with sloughing or eschar on the wound bed and epibole, undermining, tunneling, and fistula formation. Depth varies by anatomic location. If slough or eschar obscures the extent of tissue loss, it is considered an unstageable pressure injury.
Unstageable Pressure Injury—Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is completely covered by slough and/or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
Deep Tissue Pressure Injury—Persistent non-blanchable deep red, maroon, or purple discoloration: This wound is characterized by intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, stage 3, or stage 4). This term does not describe vascular, traumatic, neuropathic, or dermatologic conditions.
| A) | Health habits | ||
| B) | Medication profile | ||
| C) | History of allergies | ||
| D) | All of the above |
Health habits should be evaluated, including determination of how active the patient is, daily routines, diet, and sleep habits. Smoking, alcohol use, and illicit drug abuse can impair tissue profusion and delay wound healing [8,9].
A medication profile should be obtained, including prescription and over-the-counter medications. Certain medications will interfere with wound healing or interact with wound treatments [8,9]. For example, anti-inflammatory drugs can prolong the inflammatory phase of wound healing [12].
It is important to include a list of allergies in the medical history. For patients with latex allergy, wound care products that contain latex cannot be used. Sulfonamide antibiotics are common allergens, and silver sulfadiazine is a frequently used topical wound application. Before attempting any pharmacotherapy, the clinician must be aware of the patient's allergy history [9].
| A) | Proliferation | ||
| B) | Inflammation | ||
| C) | Hemostasis/clotting | ||
| D) | Maturation/remodeling |
Many patients with asthma require steroid therapy to control and relieve symptoms, and it is not unusual for individuals with asthma to have a prolonged history of steroid use [9]. While steroids are effective in suppressing the inflammation responsible for asthma attacks, they also block the inflammatory phase of wound healing, which is essential to wound resolution [9]. Oral or topical vitamin A may be used to decrease the anti-inflammatory effects of steroids; consultation with the treating physician on an individual basis for the possible use of vitamin A in the wound treatment plan of care is recommended [14].
| A) | eschar formation. | ||
| B) | maceration of the skin. | ||
| C) | severely limited mobility. | ||
| D) | malabsorption of nutrients. |
Approximately 10 to 13 million Americans are troubled with either transient or chronic urinary incontinence [15]. Urinary incontinence will lead to maceration (water logging) of the skin, potentiating the risk for further skin breakdown and contamination of existing wounds [9].
| A) | decreased deposition of collagen. | ||
| B) | increased production of collagen. | ||
| C) | increased strength of healed tissue. | ||
| D) | decreased risk for the development of infection. |
It is estimated that 11.6% of the American population has diabetes [16]. In these patients, elevated glucose levels can impair wound healing and negatively affect the immune system's ability to control infection. Wound healing in patients with diabetes is characterized by a decreased production and deposition of collagen and decreased strength of the healed tissue [1]. In addition, many patients with diabetes, particularly those whose disease is poorly controlled, will develop neuropathy, making the development of ulcers more likely and delaying healing.
| A) | infrequently. | ||
| B) | in centimeters. | ||
| C) | using a metal ruler. | ||
| D) | from head to toe only. |
Wounds should always be measured in centimeters, using a plastic or paper ruler. Wound length is measured from head to toe; width is measured from hip to hip. The depth of the wound can be obtained by gently inserting a sterile cotton-tipped applicator into the wound bed and marking it at skin level. The applicator is then measured using a metric ruler [1].
| A) | creates excess scar tissue. | ||
| B) | is unable to bore through muscle. | ||
| C) | is a tunnel that extends from a wound. | ||
| D) | is not a factor in the length of wound healing. |
Sinus tracts and undermining impair healing, and it is important to immediately identify their presence. A sinus tract is a tunnel that extends from any part of the wound and can bore through subcutaneous tissue and muscle. This tunnel creates dead space, which can result in abscess formation and further impede the healing process. A sinus tract can be measured using a sterile cotton swab [13].
| A) | cellulitis. | ||
| B) | tunneling. | ||
| C) | normal healing. | ||
| D) | a dry wound bed. |
The condition of the surrounding skin surface up to 4 cm from the edge of the wound circumferentially must also be assessed and documented. Its characteristics should be noted, particularly color and integrity [14]. Maceration from excessive drainage may indicate that the dressing used is not appropriate and a different product is needed. Circumferential redness up to 2 cm from the wound is indicative of cellulitis.
| A) | inflammation. | ||
| B) | nerve damage. | ||
| C) | dressing changes. | ||
| D) | All of the above |
According to the NPIAP, pressure injuries cause considerable pain and suffering [3]. Pressure ulcer pain has been described as ranging from sore to excruciating. In one study, 75% of patients rated their pain as mild, discomforting, or distressing; 18% rated their pain as horrible or excruciating [20]. Another study ranked pain according to stage of pressure ulcer and found that 50% of patients with stage 2 pressure ulcers indicated their pain was discomforting. All patients with stage 3 ulcers indicated pain was distressing, and 100% of patients with stage 4 injuries rated pain as horrible [21]. Pain and odor control are a major concern for patients, and studies have shown that patients rank pain control as more important than healing [13]. The level of pressure ulcer pain depends both on the stage of the ulcer and on manipulation of the area (e.g., if a dressing change is done at the time of assessment). The majority of patients report pressure ulcer pain at rest as well as with dressing changes. Pressure ulcer pain may be due to tissue trauma, inflammation, damaged nerve endings, infection, procedures such as debridement, and dressing changes [21].
| A) | self-report. | ||
| B) | caregiver report. | ||
| C) | skin assessments. | ||
| D) | physical examination. |
The criterion standard for assessing pain intensity is self-report using standard pain intensity instruments. Two of the most widely used pain assessment scales are the numeric pain intensity scale and the Wong-Baker Faces Pain Rating Scale [22]. The numeric pain intensity scale consists of ratings from 0 (no pain) to 10 (worst possible pain). This scale can be used for pain assessment with adults and children older than 7 years of age [6]. Visual presentation of the numeric pain intensity scale is helpful with hearing impaired patients, and the scale has been translated into many languages.
| A) | are surgically closed. | ||
| B) | are left open to heal naturally. | ||
| C) | begin to heal naturally but are eventually surgically closed. | ||
| D) | are usually deep wounds rather than partial thickness wounds. |
Wounds can also be described as healing by primary or secondary intention. Wounds resolved by primary intention are surgically closed. With secondary intention, wounds are left open and heal via the process of granulation, contraction, and epithelialization. Pressure injuries are an example of a wound that heals by secondary intention. A third classification, wounds that heal by tertiary intention, includes cases in which healing starts by secondary intention but the wound is then surgically closed [14]. Wound healing can be conceptualized as a cascade of events, and the process will differ depending on many different factors, particularly whether the wound is partial thickness or full thickness [14]. A partial thickness wound involves loss of the epidermis and usually part of the dermis [1]. These wounds are shallow, superficial, and painful. Healing of a partial thickness wound is usually a straight-forward process involving a brief inflammatory phase, cell migration, and re-establishment of normal skin layers [14]. The most important consideration with partial thickness wounds is to keep the area moist and clean. It is important to remember that a dry cell is a dead cell.
| A) | injury, assessment, treatment, and follow-up. | ||
| B) | hemostasis, inflammation, proliferation, and remodeling. | ||
| C) | proliferation, wound contraction, breakdown, and maturation. | ||
| D) | inflammation, cell migration, re-establishment of skin layers, and hemostasis. |
Full thickness wounds occur when there is destruction of the epidermis and the complete dermis. At the base of the wound, subcutaneous tissue, fascia, muscle, or bone may be visible [14]. Healing of full thickness wounds occurs in four stages: hemostasis, inflammation, proliferation, and remodeling, with considerable overlap occurring among the stages. The time frame for repair of a full thickness wound is considerably longer than that of a partial thickness wound [1]. Regardless of the cause, this biologic process of repair is the same for all acute wounds [9].
| A) | fibrin clot formation stems blood loss. | ||
| B) | the tensile strength of scar tissue is increased. | ||
| C) | the wound is resurfaced with new epithelial tissue. | ||
| D) | new granulation tissue is removed from the wound bed. |
The proliferative phase of wound healing overlaps and follows the inflammatory phase. During this process, the wound bed is filled with new granulation tissue and the wound is resurfaced with new epithelial tissue [14]. This stage can last for several weeks [9].
| A) | preserve necrotic tissue. | ||
| B) | prevent the establishment of granulation tissue. | ||
| C) | remove nonadherent debris from the wound bed. | ||
| D) | make the wound more susceptible to the growth of micro-organisms. |
The Institute for Clinical Systems Improvement (ICSI) recommends that all pressure ulcers be cleaned when first diagnosed and then with every dressing change [23,24]. The purpose of wound cleaning is to remove nonadherent debris from the wound bed in order to promote healing and make the wound less susceptible to bacterial overgrowth and infection [13]. While cleaning the wound, it is necessary to minimize trauma to the wound bed and healthy tissue [13]. Choosing the correct product for cleaning the wound is very important. Most wounds can be effectively cleaned with normal saline, a nontoxic and inexpensive product [9,24]. If used, saline must be applied to the wound with sufficient force to remove surface debris and contaminants while also minimizing trauma to the wound [1]. Normal saline used for wound cleansing should be room temperature and should be discarded within 24 to 48 hours after opening [9].
| A) | Papain | ||
| B) | Trypsin | ||
| C) | Collagenase | ||
| D) | Trastuzumab |
Enzyme formulations available for debridement include collagenase (Santyl), papain (enzymes derived from papaya), and trypsin (Granulex, Vasolex, Xemaderm); only collagenase is available in the United States [12]. Collagenase is a derivative of Clostridium bacteria and acts by liquefying the collagen bonds that fasten necrotic tissue to the underlying wound bed. The time to effect ranges from several days to weeks.
| A) | non-painful ulcers only. | ||
| B) | wounds with dry eschars. | ||
| C) | deep wounds with tunneling. | ||
| D) | shallow wounds with minimal drainage. |
Hydrogel dressings are used with shallow wounds with minimal amounts of drainage and are also a good option for painful ulcers [6]. Hydrogel dressings are usually hydrating and are either glycerin- or water-based [1]. These dressings are appropriate for use with topical medications and antibacterial agents [13].
| A) | a change in the depth of the wound. | ||
| B) | maceration of the surrounding skin. | ||
| C) | inadequate control of wound drainage. | ||
| D) | All of the above |
For nonhealing wounds, the first factor to evaluate is the quality of wound care. This includes determining if dressing changes are being carried out at the recommended intervals, if the dressings are applied appropriately, and if the manufacturer's instructions for product use are being followed [1]. Factors affecting the patient's condition should be taken into consideration and addressed appropriately. Failure of a wound to improve is often due to systemic factors, such as ischemia, infection, or malnutrition, or continuation of the causative factors. These issues must be addressed first to achieve optimum wound healing. A change in the dressing treatment is indicated if any of the following problems occur [14]:
Maceration of the surrounding skin
Inadequate control of wound drainage
A change in the amount of drainage or the depth of the wound