Apple Stages
This apple is firm, smooth, and has no bruises. What does it represent?
Healthy, intact skin
Patient has nonblanchable redness over the sacrum
Stage 1
How often should patients be turned and repositioned?
Every 2 hours
Massaging reddened skin helps prevent pressure injuries
myth
A patient says, "My heels don't hurt, so I don't need them offloaded." What should the nurse explain?
Pressure injuries can develop without pain, especially in patients with decreased sensation.
Prevention should occur based on risk, not pain
The apple has a small bruise but peel is still intact. What pressure injury stage is it?
Stage 1
Patient has a serum-filled blisted on the heel
Stage 2
Name one validated pressure injury risk assessment tool
Braden scale
Fact
True or False: A pressure injury can happen when a patient is repositioned regularly
True
This apple has a scrape where the peel has broken. What pressure injury stage is it?
Stage 2
Subcutaneous fat is visible, but bone is not.
Stage 3
Name 2 nursing interventions that reduce pressure injury risk
-repositioning
-moisture management
-nutrition
-pressure redisstribution surfaces
All pressure injuries begin as stage 1 wounds.
A patient has a reddened area over the sacrum. After repositioning and offloading the area, the redness disappears. Is this a stage 1 PI?
No, since the redness disappeared and is now blanchable. Continue PI prevention and monitor the area.
The appple has a deep cavity extending into the flesh. What pressure injury stage is it?
Stage 3
The wound bed is completely covered with slough, making depth impossible to determine
Besides pressure, name 2 additional factors that contribute to pressure injury development
-shear
-friction
-moisture
-poor nutrition
-decreased mobility
Purple discoloration over intact skin may indicate a deep tissue PI
Fact
A patient is admitted with limited mobility, poor nutrition, incontinence and decreased sensation. During your assessment, the skin is intact, but you notice a localized area of persistent purple/maroon discoloration to the sacrum.
What should you suspect and what is your priority nursing action?
Deep Tissue Pressure Injury. Immediabely offload/remove ressure from the area, protect the skin from excessive moisture, document the finding, take a photo, place a WC consult and continue to closely monitor.
The apple appears mostly normal on the outside but is badly bruised when ut open. What type of pressure injury is this?
Deep tissue injury (DTI)
Bone and tendon are visible in the wound bed
Stage 4
Which risk factor is being addressed when you prevent a patient from sliding down in the bed?
Shear
Once a stagae 4 PI heals, it becomes a stage 3.
Myth
A patient is ordered for BIPAP and the mask is tightly fitting over the bridge of the patient's nose. During a skin assessment, the RN notices non-blanachable redness underneath the device. What is the priority action?
Assess the skin and device fit/reach out to RT to help assist if needed, place a preventative foam dressing underneath the mask, reassess if bridge of nose becomes blanchable again and if not, place WC consult.